LIBRARY Urban District of Merton and Morden ANNUAL REPORT OF THE Medical Officer of Health FOR THE YEAR 1946 AND REPORT OF The Sanitary Inspector Urban District of Merton and morden ANNUAL REPORT OF THE Medical Officer of Health FOR THE YEAR 1946 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 1946. It is very gratifying to be able to put before you such a satisfactory picture as this year's annual statistics present. This year, the second post-war year, shows evidence of the remarkable recovery in our vital statistics. In fact the recovery is national as well as local. The year 1946 is a year of records as far as public health statistics go. Our population at 73,590 is the highest ever recorded, higher by 7,500 than the previous highest which was reached in 1939. Our births this year number 1,292, an absolute record, with a natural increase—that is excess of births over deaths of 693—again a record. To complete the outline of this very satisfactory picture we can point to the maternal mortality rate of nil and an infant mortality rate of 22 per thousand live births. The latter, again a record. An increasing number of our births are taking place in hospitals and maternity homes. Actually, 923 out of a total number of births of 1,292 or 71.5 per cent. There is a table on page 10 showing the growth of this tendency. The total number of deaths was 568, giving a death rate of 7.7 per thousand population as compared with 8.5 per thousand population for England and Wales as a whole. As regards infectious disease, there has been nothing noteworthy during the year. Measles assumed epidemic proportions with 568 cases, and consequently continued to maintain an annual incidence of over a hundred eases, as in the past five years. There were only 9 cases of diphtheria, one more than in 1944 which was a low record. It only remains for me to express my sincere gratitude to the members of the Council and the staff of the department, with whom I share responsibility for the public health work in Merton and Morden, for their unfailing enthusiasm and support. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, A. W. JOHNS. September, 1947. 2 \ URBAN DISTRICT COUNCIL of MERTON and MORDEN 1946 PUBLIC HEALTH COMMITTEE Chairman: Mr. J. A. Farnham. Mr. J. H. Burrows. Mrs. H. Cobbett. Mrs. L. A. Doel. Mr. D. R. Fentiman. Mr. F. J. Matthews. Mr. S. C. A. Miller. Mr. D. W. Reimers. Mrs. S. A. Lodge. Mr. F. J. Grimme, J.P. (ex-officio). Mrs. E. M. Clifton, J.P. (ex-officio). MATERNITY AND CHILD WELFARE COMMITTEE Chairman : Mrs. S. A. Lodge. Mr. J. H. Burrows. Mr. W. G. Oliver. Mrs. H. Cobbett. Mr. D. W. Reimers. Mrs. L. A. Doel. Mrs. H. Davison r, Mr. S. C. A. Miller. Mr. F. J. Grimme, J.P. (ex-officio). Mrs. E. M. Clifton, J.P. (ex-officio). REPRESENTATIVES ON THE WANDLE VALLEY JOINT HOSPITAL BOARD. Mrs. H. Cobbett. Mr. A. E. Davison. Mr. C. S. Marsh. Mr. F. J. Grimme, J.P. (ex-officio). REPRESENTATIVES ON THE WANDLE VALLEY JOINT SEWERAGE BOARD. Mr. S. F. Franklin. Mr. H. J. Simons. Mr. W. King. Mrs. E. M. Clifton, J.P. (ex-officio). REPRESENTATIVES ON NELSON HOSPTAL COUNCIL. Mrs. E. M. Clifton, J.P. Mr. E. W. Warren. Mr. J. A. Farnham. MERTON AND MORDEN TUBERCULOSIS CARE COMMITTEE Mr. J. A. Farnham. Mr. F. J. Matthews. Mrs. A. E. Edwards Mrs. E. L. Kimber Co-opted members. Chairman : Mrs. H. Cobbett. Vice-Chairman : Mrs. M. E. Shaw. Secretary : Miss N. L. Tayler. Treasurer : Mr. F. S. Buck. 3 PUBLIC HEALTH STAFF, 1946. Mcdical 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: ade F. C. Thomas, M.R.San.I. Deputy Chief Sanitary Inspector: bdf W. T. Pinches, M.R.San.I. (From 1.5.46). Sanitary Inspectors: c g C. JONES, M.S.I.A. bdf N. SMITH, M.S.I.A. Senior Health Visitor: Miss E. M. Sperry. Health Visitors: Miss M. E. Black. Miss J. Eve. Miss A. Howard Miss E. F. Martin Miss V. M. Evans. Chief Clerk : A. A. Makepeace (with H.M. Forces to 22.9.46). H. J. Herbert (Acting to 22.9.46). Clerks: R. J. Mitton (with H.M. Forces to 31.3.46). B. J. Fentiman (with H. M. Forces to 28.2.46). Mrs. M. Green (To 30.11.46). Miss J. Matthews (To 31.8.46). A. J. Fletcher (To 9.3.46). Ante^Natal Officer: Christine Stacey, M B., B.S., M.R.C.O.G. (To 9.11.46). Stanley Arthur Bond, MB., Ch.B., M.R.C.O.G. (From 14.11.46). 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.). Dented Attendant and Home Help Organiser : Mrs. W. E. Robertson (From 1.4.46). a Sanitary Inspector's Certificate, Royal Sanitary Institute. 6 Sanitary Inspector's Certificate, San. Insp. Exam. Joint Board. c Sanitary Inspector's Certificate, Sanitary Association, Scotland. d Meat and Food Inspector's Certificate, Royal Sanitary Institute. e Sanitary Science Certificate, University of Liverpool. / Smoke Inspector's Certificate, Royal Sanitary Institute. g Meat and Food Certificate, Royal San. Assn. of Scotland. 4 SECTION A.— STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 3,238 Number of inhabited houses according to Rate Books 21,065 Rateable value at 31st December, 1946 £644,253 Sum represented by 1d. rate £2,560 Lying in the valley of the Thames and naturally drained by its tributaries the River Wandle and the Pyl and Beverley Brooks, the district is flat. The surface rises gently from the northern or Wimbledon boundary toward the southern limit of the Morden Ward, the whole lying between the 42ft. and 141ft. ordnance datum levels. The subsoil is sand in the north-eastern part and merges into clay which extends throughout the greater part of the district lying to the south. The Urban District forms part of the London " dormitory area " and the majority of its wage earners earn their livelihood in the County of London. Industry. The number of factories registered under the Factory Act at the end of 1946 was:— Factories with mechanical power:— Employing more than 40 persons 36 Employing less than 40 persons 136 Factories without mechanical power 18 190 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 40 Total number of persons in receipt of domiciliary assistance on:— 1st January, 1946 303 1st July, 1946 282 31st December, 1946 278 Total amount of domiciliary assistance granted in Merton and Morden in the year 1946 £10,005 13 8 5 Climatic Conditions. Rain gauges are installed at the Joseph Hood Recreation Ground and West Barnes Pumping Station. The monthly recordings are as shown below:— RAINFALL, 1946. JOSEPH HOOD RECREATION WEST BARNES PUMPING GROUND STATION Month Inches 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 1.48 10 8 1.85 15 11 February 2.12 17 11 2.39 19 13 March 1.09 7 5 1.28 11 5 April 2.13 11 10 2.25 11 9 May 3.50 13 10 3.62 16 10 June 2.04 18 15 2.52 20 16 July 1.15 8 7 1.24 10 6 August 4.09 19 15 4.56 21 18 September 2.56 18 15 2.93 21 16 October .99 11 7 .91 11 7 November 3.19 22 18 3.57 24 19 December 2.29 18 14 2.56 24 15 Total 26.63 172 135 29.68 203 145 VITAL STATISTICS. Reference to the figures shown in Table I on page 9 provides a comparison in vital statistics very favourable to our district. It will be seen that our various death rates, mortality rates, etc., are compared with those of the County Boroughs and great towns including London and similarly towns with 25 to 50 thousand population, London County and England and Wales as a whole. Although our birth rate is lower than those with which it is compared in the Table, it will be seen by reference to Table II on page 12 that for us it is a very good rate; in fact, except for the years 1943 and 1944, when it was also high, it is higher than it has been since 1923 and, moreover, the total number of births at 1,292 is an absolute record. Our figures for deaths from all causes is well below the other figures, 7.7 per thousand, as compared with 11.5 per 1,000 for England and Wales. Our infant mortality rate is 22.2 per thousand live births, compared with 43 per thousand for England and Wales. Our maternal mortality is nil. 6 The total deaths from all causes was 568 and the total live births 1,261, giving therefore a natural increase in population of 693. The appended table sets out the comparison for the past five years of the local infant mortality rate with that for England and Wales:— England and Wales. Merton and Morden. 1942 49 33.9 1943 49 23.5 1944 46 28.7 1945 46 33.1 1946 43 22.2 The number of illegitimate births has again dropped slightly this year. Further details regarding arrangements for the care of illegitimate children and their mothers are given on page 32. 7 SUMMARY OF VITAL STATISTICS. (Registrar General's Figures), Population: Registrar General's Estimate 73,590 Births: M. F. Total Live (Legitimate) 673 543 1,216 (Illegitimate) 26 19 45 699 562 1,261 Stillbirths (Legitimate) 16 15 31 (Illegitimate) — - - 16 15 31 Total Births 715 577 1,292 Birth Rate 17.1 per 1,000 population Still Birth Rate 23.9 per 1,000 births Deaths: M. F. Total 305 263 568 Death Rate 7.7 per 1,000 population Infant Mortality: Total deaths under one year ... 28 Infant Mortality Rate per 1,000 Live Births 22.2 Deaths of Legitimate Infants under 1 year 27 Death Rate per 1,000 Legitimate births 22 Death Rate per 1,000 Illegitimate births 22.2 Maternal Mortality: Deaths from Sepsis Nil Deaths from other maternal causes Nil Maternal Death Rate — Zymotic Deaths: Deaths from Measles Nil Whooping Cough Nil Diarrhoea (under 2 years) 1 7 Principal Zymotic Diseases 1 Zymotic Death Rate (per 1,000 population) 0.01 Deaths from Tuberculosis: All forms 42 Rate per 1,000 population 0.57 Phthisis 37 Rate per 1,000 population 0.50 Deaths from Cancer 126 Rate per 1,000 population 1.71 8 TABLE I. COMPARATIVE STATISTICS, 1946. (Registrar General's Figures with Corresponding Figures for Merton and Morden added). England and Wales. 126 County Boro's and Great towns including London. 148 Smaller Towns (Residential Populations 25,000 to 50,000 at Census). London tive County, Merton and Morden. Rates per 1,000 Population. Births:— Live 19.1 22.2 21.3 21.5 17.1 Still 0.53 0.67 0.59 0.54 0.42 Deaths:— All causes 11.5 12.7 11.7 12.7 7.7 Typhoid and Paratyphoid fevers 0.00 0.00 0.00 0.00 0.00 Scarlet fever 0.00 0.00 0.00 0.00 0.00 Whooping Cough 0.02 0.02 0.02 0.02 0.00 Diphtheria 0.01 0.01 0.01 0.01 0.00 Influenza 0.15 0.13 0.14 0.12 0.12 Smallpox 0.00 0.00 0.00 — 0.00 Measles 0.00 0.01 0.00 0.01 0.00 Notifications:— Typhoid Fever 0.01 0.01 0.01 0.01 0.00 Paratyphoid fever 0.02 0.02 0.01 0.01 0.00 Cerebro-spinal fever 0.05 0.05 0.04 0.06 0.01 Scarlet fever 1.38 1.51 1.33 1.42 1.72 Whooping Cough 2.28 2.48 2.05 2.22 3.23 Diphtheria 0.28 0.32 0.31 0.24 0.12 Erysipelas 0.22 0.25 0.22 0.27 0.13 Smallpox 0.00 0.00 0.00 0.00 0.00 Measles ... 3.92 4.73 3.70 7.35 7.27 Pneumonia 0.89 1.02 0.74 0.75 0.95 Rates per 1,000 Live Births. Deaths under 1 year of age 43 46 37 41 22.2 Deaths from Diarrhoea and Enteritis under 2 years of age 4.4 6.1 2.8 4.2 0.71 Rates per 1,000 Total Births (Live and Still). Notifications:— Puerperal fever Puerperal pyrexia 8.50 10.35 7.63 1.62 9.68* 7.7 * Including Puerperal Fever. 9 POPULATION. The Registrar General has estimated the population for 1946 as 73,590. This is 7,540 more than his estimate for last year, and by this very generous increase has adjusted this figure to what is regarded locally as an approximate figure. It is in fact the highest population figure he has ever given us, the nearest being in 1939 when the estimate figure was 72,150. BIRTHS. As has been recorded, the registered live births total 1,261, 234 more than last year, but owing to the highest estimated population on which the birth rate has been calculated, the birth rate has actually fallen from its highest figure since 1923—of 18.3 in 1944 to 17.1 this year, though it is still higher than last year, 17.1 as compared with 15.5. INSTITUTIONAL AND DOMICILIARY BIRTHS. The notifications show that 923 births took place in institutions, hospitals and private nursing homes. This is 150 more than in 1945 and represents 71.5 per cent, of the total. They occurred in the following hospitals, etc.:— St. Helier County Hospital 439 Nelson Hospital 209 Kingston County Hospital 18 Other hospitals, institutions and nursing homes 257 923 The increased trend towards institutional rather than domiciliary maternity was apparent in the pre-war years, and was no doubt taken into account in estimating the future bed need at that time. The rapid acceleration of this trend for housing and other domestic reasons, the great increase in the birth rate and the shortage of nursing staff—these factors which have created our present difficulties could hardly have been foreseen. Hospitals have therefore been compelled to establish a system of priorities for admission. The arrangements whereby cases have been admitted into hostels in the rural areas prior to the onset of labour and admitted to the hospital at the onset of labour have afforded relief in many anxious domestic situations in our very highly 10 populated areas where the pressure on maternity beds is great. In spite of the inevitable occasional B.B.A. in such circumstances the arrangements have made a valuable contribu tion towards easing a very difficult situation. The high figure of 257 births in other hospitals, institutions and nursing homes bears witness to the extent to which arrangements have been made outside the area in this and other ways. Some figures which were prepared for a special conference called during the year to deal with the problem of the shortage of maternity beds are reproduced as they may be of wider interest :•— Comparison of Domiciliary and Institutional Births in 2 years prior to the war, 1938 and 1939 and in 1944, 1945 and 1946. Year No. of Institutional No. of Domiciliary Total Percentage of Institutional Births. Births. Births. Births. 1938 560 457 1,017 55% 1939 558 477 1,035 55% 1944 778 399 1,177 67% 1945 773 280 1,053 73% 1946 923 369 1,292 71% 11 TABLE II. Showing Births and Deaths with Rates since the Amalgamation of Merton with Morden. Year. Estimated population. Total Births. Birth Rata, Total Deaths. Death Rate. Natural Increase 1913 16,767 400 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 1916 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 11.6 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 14.3 503 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 8.8 481 1943 65,880 1,146 17.4 575 8.7 571 1944 62,760 1.151 18.3 628 10.0 5-23 1945 06,050 1,0-7 15,5 602 9.1 425 1046 73,590 1,261 17.1 568 7.7 693 DEATHS. The number of registered deaths after adjustment bytransferable deaths, is given below:— 568 total deaths of which 305 were male and 263 females. The seasonal mortality is indicated by the deaths for each quarter of the year, which were:— First quarter Second quarter Third quarter Fourth quarter 162 134 112 160 12 Inquests. Inquests were held on 31 deaths occurring in the district, 15 of which were in respect of residents. The verdicts returned were as follows:— (1) Natural Causes 3 (2) Suicide by— Coal Gas Poisoning . 3 Strangulation by Hanging 2 Bullet Wound in Head 1 Run over by Train 1 — 7 (3) Accidental Deaths— Collision with motor vehicles 12 Toxaemia following burns 2 Pall in street 1 Fall from moving train 1 Coal Gas Poisoning I — 17 (4) Misadventure— Shock following operation 1 (Congenital Hydrocephalus) Status Lymphaticus accelerated by ether anaesthesia 1 2 (5) Unclassified— Multiple injuries by being run over train 1 Coal Gas Poisoning 1 — 2 31 The total number of inquests held were five more than in the year before. Road accidents were responsible for twelve of the total accidental deaths, compared with six for the previous year. CAUSES OF DEATH. The commonest single cause of death in the list of causes this year is cancer with 126 and the next common cause heart disease with 125, that is just a reversal of the usual order. Although, as pointed out last year when the greater accuracy of certification of cancer is borne in mind, it is likely that cancer is genuinely the commonest single cause. As will be seen on page 14 its rate has been 1.7 per thousand for the past four years and it has risen only 0.3 per thousand in the past decade. 18 There were 37 deaths from tuberculosis of the respiratory system, 21 males and 16 females, and there were 5 deaths from non-respiratory tuberculosis of whom 3 were males and 2 females, giving a total number of deaths of 42 as against 45 in 1945 and 37 in 1944. CANCER DEATH RATE. No. of deaths from Cancer for past 10 years. 1937 93 1942 103 1938 89 1943 116 1939 91 1944 107 1940 76 1945 116 1941 85 1946 126 Year. \ Death Rate per 1,000 population. Y ear. Death Rate per 1,000 population. 1937 1.4 1942 1.5 1938 1.2 1943 1.7 1939 1.1 1944 1.7 1940 1.2 1945 1.7 1941 1.3 1946 1.7 TABLE III. Deaths from Respiratory Diseases, 1926-1946. Year Bronchitis Pneumonia Other Respiratory Diseases Total Death Rate 1926 6 8 6 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 1981 8 24 4 86 0.8 1982 11 27 8 41 0.8 1988 12 82 6 50 0.9 1984 7 88 4 49 0.8 1985 9 22 6 37 0.6 1986 2 35 2 89 0.6 1987 14 81 6 51 0.8 1988 15 27 7 49 0.7 1989 5 20 9 84 0.4 1940 38 40 15 93 1.8 1941 80 80 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 1946 6 22 12 70 1.05 1916 22 17 17 56 0.76 11 TABLE IV. Causes of Death during the Year 1946. No. Cause of Death. Males Females Total 1 Typhoid and Paratyphoid Fevers - - - 2 Cerebro spinal fever — — — 3 Scarlet Fever — — 4 Whooping Cough — — — 5 Diphtheria — — — 6 Tuberculosis Respir. System •21 16 37 7 Other forms of Tuberculosis 3 2 5 8 Syphilitic diseases 1 2 3 9 Influenza 4 5 9 10 Measles — — — 11 Ac. Polio-myel. and polioencephalitis — — 12 Ac. inf. encephalitis - — — 13 Cancer of bue. cav. and oesoph. (M) uterus (F) 3 6 9 14 Cancer of stomach and duodenum 12 10 22 15 Cancer of breast 1 9 10 16 Cancer of all other sites 54 31 85 17 Diabetes — 2 2 18 Intra-cranial vascular lesions 21 29 50 19 Heart disease 59 66 125 20 Other dis. of circ. system 9 12 21 21 Bronchitis 14 8 22 22 Pneumonia 12 5 17 23 Other respiratory diseases 10 7 17 24 Ulcer of stom. or duodenum 11 1 12 25 Diarrhoea under 2 years 1 — 1 26 Appendicitis 2 — 2 27 Other digestive diseases 4 6 10 28 Nephritis 5 9 14 29 Puer. and post abort, sepsis — — — 30 Other maternal causes — — — 31 Premature birth 2 2 4 32 Con. mal. birth inj. inf. dis. 14 7 21 33 Suicide 5 2 7 34 Road traffic accident 5 — 5 35 Other violent causes 6 4 10 36 All other causes 26 22 48 Total all causes 305 263 568 MATERNAL MORTALITY. The maternal mortality in our area this year is nil. That is to say, no woman resident of our district died as a result of childbirth, either within the district, or in hospital or nursinghome outside the district. If we turn up the records, we have to go back to 1928 to find such a fortunate occurrence, though our maternal mortality as the figures on page 16 will show is consistently low. 15 TABLE V. Maternal Mortality, 1926-46. Year Death rate per thousand total births. Sepsis Other causes Total 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 7.6 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 1940 — — - INFANT MORTALITY. It has always been a source of pride to us that our infant mortality rate is consistently year by year below the rate for the country as a whole. It is of course much below the great towns, among whom are to be found the areas which contribute to raising the national rate, and it is in fact invariably below the smaller towns, among whom are to be found the areas whose rates are the most favourable and whose contribution is towards a reduction of the national rate. To obtain the greatest possible gratification out of these facts, we generally remind ourselves and any others who may chance to read our annual report, that a special significance is attached to the infant mortality rate. That, in fact, a healthy environment for a baby indicates a high standard of environmental hygiene of child care and of mothercraft. Like the child and a favourite story, we never tire of hearing this. We only hope our figures will never deny us the opportunity. 16 In the past few years the causes of infant deaths with the ages at death have been set out in full to illustrate that the reduction of the number of infant deaths does not lie any longer to any extent in the care of the child. This is demonstrated by the fact that the greatest number of deaths occur in the first month of life from causes which are attributable to childbirth or to faults in the infant"s own intrauterine development. As proof of this fact the 1946 figures are startling in their bias. All of the infant deaths are neonatal deaths. To allay any possible suspicion and to give a more balanced picture, it should perhaps be mentioned that for the two previous years these deaths have been analysed in this way. In 1945 there were 29 neonatal deaths out of a total of 34 and in 1944 there were 18 out of a total of 33. As has been said before any serious further economy in these infant lives can only be effected in the ante-natal and obstetric departments. Misgiving has sometimes been expressed about the value of these weaklings to the community if by further efforts some of them could be saved. It is only necessary to point out that in 8 of these 28, prematurity is given as a cause of death. It is difficult to see how the denial of a few further weeks of intrauterine life by the premature release of a trigger mechanism which is not understood and which results in childbirth some weeks earlier than it should occur, can be regarded as evidence of the ultimate unfitness of the infant for our community. Infant Deaths—With causes of death. Sex. Age. Cause of Death Male 7 months Acute Lobar Pneumonia. Female 3 days Prematurity. Male 3 days Atelectasis Spinal cord damaged during delivery. Male 1 month Tuberculous Pneumonia. Female 1 day Congenital Heart Disease. Male 2 days Congenital Heart Disease. Male 6 months Congenital Heart Disease— an Arterio-venus junction. Male 1 month Hydrocephalus Spina Bifida. Male 20 minutes Hasmatoma due to tear of Tentorium Cerebellum. Female 2 days Prematurity. Female 25 minutes Spina Bifida. Male 1 week Lobar Pneumonia. 17 Sex. Age. Cause of Death Male 9 months Pyelonephritis. Male 6 days Kernicterus Erythroblastosis fœtalis Prematurity. Male 2 hours Congenital Diaphragmatic Hernia and Congenital Morbus Cordis Intra cranial Haemorrhage. Male 3 days Cerebral Haemorrhage. Female 4 days Congenital Cardiac Malformation. Male 1 week Congenital Valvular Disease of the Heart. Male 1 day Prematurity Male 4 days Pulmonary Hemorrhage. Male 7 days Imperforate Anus. Female 1 week Atelectasis Prematurity Toxaemia of Pregnancy. Female 1 day Cyanosis Spina Bifida. Male 1 month Gastro enteritis Prematurity. Male (Twins) 12J hours Atelectasis of Lungs 3 hours and Prematurity. Natural Death. Male 2 days Prematurity. Female 5 days Peritonitis Ruptured Colon Congenital Pelvic Rectal Stenosis. PREMATURE BABIES. It has been stated that premature children weighing less than 1,500 g. (3.3 lbs.) and measuring less than 35 cm. in length have practically no chance of life. This statement we know is not entirely true but it remains true that the infant's chances of survival decrease in direct ratio to its prematurity and the reduction of its birth weight. Foetal weights have been variously computed, but if we take it that the infant does not generally reach 5^1bs., the premature birth notification weight— until the end of the 36th week, it is clearly imperative fhat any births before this time should be in hospital both for their especial care there and to avoid the possibility of exposure and chill in transport, It is an aphorism not yet perhaps widely enough appreciated that the best arrangements are for the baby to be taken to hospital in utero. If we risk pursuing this weight argument 18 a little further and use the generally accepted 4½ lb. weight as essential hospitalisation weight, it follows that according to intrauterine weights it is not until the 34th week that the foetus reaches 2,041 g. or 4£ lbs. It is therefore even more urgent where a woman not more than 34 weeks pregnant shows any indication of the onset of labour that she shall immediately be sent to a hospital where there are special arrangements for dealing with premature babies. St. Helier Hospital continues to provide the special institutional accommodation for our cases, and by arrangement furnishes us with full details on discharge to enable any special measures to be continued. The hospital provides a specially equipped ambulance for the transport of these cases, designed to prevent loss of body heat in transit. We provide special equipment for cases born at home and remaining at home, including a special cot. The services of a paediatrician are also available for consultation in the home, by direct call or through the department. Special emphasis has recently been laid on the availability of breast milk in these cases. No bank for breast milk has been established in the area but there is no doubt that breast milk could be provided if such was advised in any particular case. The total number of premature babies notified during the year were as follows, born :— (a) At home 6 (b) In hospital 17 The number of those born at home:— (a) Who were nursed entirely at home 6 (b) Who died during the first 24 hours — (c) Who survived at the end of one month 6 The number of those born in hospital:— (a) Who died during the first 24 hours 2 (b) Who survived at the end of one month 13 19 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 182 cases involving 1,478 visits were attended during the year and of these 15 cases were children under 5 years of age, to whom 46 visits were made. (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 181 cases were dealt with by the St. Helier District Nursing Association, 6 of these were children under 5 years of age. The total number of visits made was 2,141, of which 36 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 figures relating to cases and visits in this district during the year are as follows:— Cases. Visits. Children under 5 years 30 155 Other cases 345 5,936 375 6,091 Laboratory Facilities. The routine laboratory work for the 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 286 5 Sputum for Tubercle Bacilli 45 2 Fasces 95 7 20 AMBULANCE FACILITIES. Infectious Cases. Cases of infectious disease, where they are admitted to Isolation Hospital, are conveyed by the ambulance 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. Arrangements exist between Sutton and Cheam, Carshalton, Mitcham and Merton and Morden whereby calls are transmitted by one authority to the nearest available, when the ambulance is already out, this reciprocal arrangement being free between the authorities concerned. The scope of the work undertaken by our ambulance is as shown below— AMBULANCE CALLS, 1946. Month Calls received from Public Calls received from neighbouring Brigades Total Galls Received Calls trrtnsferred to other Brigades Calls answered by Own Ambulance Jan. 127 19 146 16 180 Feb. 93 19 100 7 99 March 102 20 122 11 111 April 107 12 119 10 109 May 99 12 111 12 99 June 105 18 118 12 106 July 115 80 145 18 182 Aug. 77 26 103 85 68 Sep. 107 19 126 4 122 Oct. 106 81 187 8 129 Nov. 188 26 159 17 142 Dec. 171 86 207 80 177 Total 1342 267 1599 175 1424 Time taken in executing the calls (from leaving Station to return) 1,146 hours Mileage covered. 11,998 miles Average time per call 48.3 minutes Average distance per call 8.4 miles The Hospital Car Service was continued during the year under the auspices of the British Red Cross and St. John Ambulance Brigade. This service caters for ambulance patients who are required to attend out-patient departments of hospitals for treatment. The work is undertaken 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 of the district. These arrangements are a most valuable extensior of the ambulance facilities provided in the district. 21 . CLINICS AND TREATMENT CENTRES. 1.—Maternity and Child Welfare Clinics (provided by the Council). Centre Clinic Times of Clinics Health Centre Grand Drive, Raynes Park, S.W.20 Infant Welfare Monday 10— 12 noon. ,, 2— 4 p.m. Wednesday 10—12noon Ante-Natal Wednesday at 1.80 p.m. Health Centre, Aston Road, Raynes Park, S.W.20 Infant Welfare Wednesday 2—4 p.m. Friday 10—12 noon Ante-Natal Saturday at 9.0 a.m. Dental Clinic By appointment Friday mornings. Health Centre, Middleton Road, Morden Infant Welfare Tuesday 11—12 noon. ,, 2— 4 p.m. 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, Ravnes Park, S.W.20 Minor Ailments Every Tuesday and Thursday 9.80—12 noon. Dental Every Monday, Tuesday and Thursday 9.80—12 noon 1.80—4.0 p.m. Every Friday 1.80—4.0 p.m. Eye Every 2nd, 4th and 5th Tuesday afternoon in the month. Middleton Rd., Morden Minor Ailments Every Monday and Wednesday 9.80—12 noon. Dental Every Tuesday, Wednesday and Friday 9.80—12 noon and 1.80—4.0 p.m. Every Monday and Saturday 9.80—12 noon. Every Thursday 1.80-4.0 p.m. Eye Every Wednesday afternoon 2.0 to 4.80 p m. 22 3.—Tuberculosis Dispensaries (provided by the Surrey County Council). St. Helier County Hospital Wrythe Lane, Carshalton, Morden Patients Monday 10 a.m. 2nd Monday in month, 6.80 p.m. Friday 1.80 p.m. Merton and 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, Mitcham, Beddington and Wallington and Coulsdon and Purley. The hospital has accommodation for 196 patients, including cubicle isolation for 38. During the year 146 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 actual staffing of the hospital, both nursing and domestic, still presents a big problem and the position has not eased in any way during the year. 23 TABLE VI. Cases admitted to the Wandle Valley Isolation Hospital during the Year 1946. Disease. Cases Deaths Diphtheria 9 — Scarlet Fever 95 — Erysipelas 4 — Tonsillitis or Quinsy 12 — Measles 3 — Influenza 1 — Whooping Cough 2 — Rubella 2 — Meningitis, all types, including T.B. Meningitis 2 2 Puerperal Fever (Sepsis) 3 — Admitted with Mother 3 — Infantile Paralysis 2 — Dermatitis 2 — Laryngitis 2 — Bronchitis 1 — Pneumonia 1 1 Otitis Media 1 — Cerebral Haemorrhage l - Total 146 8 General and Maternity. 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 105 beds, 25 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 number of in-patients admitted 1,392 Number from Merton and Morden 482 Total number of new out-patients 8,740 Number from Merton and Morden 3,944 24 (b) Maternity Services. Number of patients admitted from all districts during the year:— (1) General Wards 349 (2) Private Wards 157 506 Number of patients admitted from Merton and Morden:— (1) General Wards 144 (2) Private Wards 83 227 2. The County and Public Assistance Hospitals. In addition to the voluntary accommodation described above, there is available to the district various County Hospitals. St. Helier Hospital with a bed complement approaching a 1,000, is only just outside the boundary and both Kingston and Epsom Hospitals are within five miles or so. St. Helier Hospital, which is destined to be the key hospital for this and neighbouring areas, at an rate for some years, has 795 medical and surgical beds and 97 maternity beds. Tuberculosis. The County Sanatorium, Milford—300 beds. The Surrey County Council is responsible for the AntiTuberculosis Scheme in the district. The County Sanatorium at Milford constitutes the main institutional provision, and 17 persons were admitted from Merton and Morden during the year, whilst 64 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, as mentioned elsewhere in this Report, is largely contributed to by shortage of nursing staff. 25 MATERNITY AND CHILD WELFARE. Public Health Act, 1936, Section 203—Notification of Births. The births notified under Section 203, as adjusted by transferred notifications, were as follows:— Live Births 1,214 Still Births 28 1,242 Notified by Midwives 493 Notified by doctors and parents 15 Transferred from other districts 734 1,242 The Work of the Centres. The work of the Centres continues to expand and this year shows a record number of attendances and a record number of children on the clinic register. Reference to Table IX on page 28 reveals the steady growth of the work over the past ten years. It will be seen that the figures for 1946 are with one exception record figures. The number of mothers who attended the ante-natal clinics is 1,082, which is nearly 30 per cent. more than in any previous year. Moreover, 86 per cent. of our expectant mothers in the district attend our ante-natal clinics. When it is remembered that some other of our mothers are attending ante-natal clinics at the Nelson Hospital and at St. Helier Hospital, it will be appreciated that a remarkably large proportion of the expectant mothers in the district are having ante-natal care. Table VIII shows the number on the register at the various clinics. It will be observed that the Raynes Park clinic and the Baptist Hall have attendances averaging 70 to 75 per session. It should be remembered that there will be many occasions when the attendances are greatly in excess of this number to produce such an average. The average at the Morden clinic of 31.5 per session is a somewhat fictitious figure; it should be about 50 per session, the reason being that one session per week has been held there with negligible attendances. These have now been discontinued. 26 TABLE VII. Attendances at Ante-Natal Clinics. Clinic No. on Register Attendances Sessions Average per Session Primary Total Morden Ante-Natal 410 342 1897 56 34.6 Post-Natal 40 — 41 Individuals 450 342 1938 Raynes Park Ante-Natal 237 179 1094 52 21.8 Post-Natal 18 — 17 Individuals 255 179 1111 Grand Drive Ante-Natal 332 282 1454 54 27.9 Post-Natal 45 5 51 Individuals 377 287 1505 All Clinics Ante-Natal 979 803 4445 162 28.1 Post-Natal 103 5 109 Individuals 1082 808 4554 (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.) 27 TABLE VIII. Attendances at Infants' Consultation Clinics. Centre No. on Register Attendances Sessions Average Attendance per Session Primary Total Morden Under 1 yr. 594 249 3,304 143 31.5 1-5 years 21 1,210 Raynes Park Under 1 yr. 743 261 4,062 99 69.4 1-5 years 36 2,818 Baptist Hall Under 1 yr. 402 132 1,962 43 75.2 1-5 years 11 1,272 Hope Mission Under 1 yr. 190 68 1,201 51 39.5 1-5 years 8 815 Grand Drive Under 1 yr. 852 304 4,842 145 55.9 1-5 years 51 3,274 All Centres Under 1 yr 2,781 1,014 15,371 481 51.4 1-5 years 127 9,389 * Excluding children known to have attended other Centres. TABLE IX. Attendances at all Centres over last 10 years. Year No. of Infants Attending during year No. of Women attending Maternity Clinics ATTENDANCES Grand Total infants Maternity Primary under 1 yr Total 1937 2,250 358 569 20,422 1,450 21,872 1938 2,800 469 750 25,235 2,127 27,362 1939 3,090 588 856 24,376 2,395 26,771 1940 2,614 668 705 17,255 2,364 19,619 1941 2,445 595 745 17,955 2,272 20,227 1942 2,731 774 840 21,478 1,341 22,819 1943 2,514 681 908 22,435 2,074 24,509 1944 2,491 740 807 15,992 2,948 18,940 1945 2,697 762 870 22,855 3,292 26,147 1946 2,781 1,082 1,014 24,760 4,554 29,314 28 TABLE X. Number of Children under One Year and Expectant Mothers attending the Centres in relation to the Registered Births. Year Registered births Infants under 1 year Mothers who attended either Ante-Natally or Post-Natally. Primary attendances Percentage of registered births Number attended Percentage of registered births 1926 333 124 37 1927 352 168 46 1928 392 386 98 50 12.7 1929 442 394 89 44 9.9 1930 452 446 98 49 10.8 1931 628 1,030 164 190 30.3 1932 770 1,089 141 245 31.8 1933 640 825 128 220 34.3 1934 770 545 70 233 30.2 1935 721 554 77 253 35.0 1936 789 561 71 306 39.0 1937 812 569 70 358 44.0 1938 990 750 75 469 47.8 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 1946 1,261 1,014 80 1,082 85.8 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 afternoon and a Pædiatric Clinic every Monday afternoon. The hospital is a voluntary organisation serving Wimbledon, Merton and Morden. The following information relating to the ante-natal and post-natal clinics of the hospital has been kindly supplied by the Secretary, indicating the number of attendances during the year:— 29  Ante-Natal. Post-Natal. Total number of attendances from all districts during the year 1,959 268 Total number of women who attended during the year:— (a) From Merton and Morden 154 109 (b) From all districts 375 234 Health Visiting'. 200 births used to be regarded as the guide as to the maximum size of the area which one health visitor could cover, so that it will be appreciated that an increase of 234 births must have repercussions on the work of the health visitors. In addition to this there has been a steady increase in the ante-natal work not only by virtue of the increase in the number of births but because of the requests for reports on home conditions to help Hospital Almoners to decide priorities of institutional need. As I have already mentioned the health visitors have not been able to keep up with the expansion in the volume of work. While the births have increased by 234, the follow up visits have only gone up by 157, and while there were 55 more visits to expectant mothers than in the previous year, there were in fact 234 more expectant mothers, which is, of course, further proof of the same fact. The report therefore provides statistical evidence of knowledge already in the possession of the Committee and on which they have already acted by making provision for an additional health visitor next year. The number of visits made for the various purposes was as shown below:— To expectant mothers—first visits 553 total visits 810 To children under 1 year—first visits 1,341 total visits 4,130 To children—1-5 years—total visits 4,059 Visits re puerperal pyrexia, ophthalmia neonatorum and miscellaneous 401 Visits to foster children re Child Life Protection 138 9,538 30 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. Orthopædic 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. Complicated cases requiring in-patient treatment are referred to hospitals locally, while cases complicated by pyrexia received treatment at the Wandle Valley Isolation Hospital. 152 such cases from the Council's Maternity Clinics were referred during the year to the following institutions:— To the St. Helier County Hospital 141 To the Kingston County Hospital 4 To other hospitals 7 The reasons for referring these cases were as follows:— For obstetrical abnormality 55 For other medical reasons 48 For unsuitable home conditions 49 During the year 209 maternity cases were admitted to the Nelson Hospital and 439 to the St. Helier County Hospital. Cases admitted to other hospitals, institutions and nursing homes numbered 275, making a total of 923, or 71.5 per cent. of the total births. 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 Council employs an organiser, two full time home helps and ten part time. It will be seen by reference to the tabulated statement below that 115 cases were dealt with during the year of which 72 were under the Maternity 31 and Child Welfare arrangements and 43 in the domestic category. If the allocation were expressed in hours of working time, it would present a very different picture, the Maternity the Child Welfare cases are generally for short periods during confinement or temporary illness, while the domestic are generally long term commitments in such cases as old age and infirmity. Recruitment of additional part time workers is still difficult and the success of such a scheme depends on almost day to day disposition of forces available. This can be done by an organiser responsible for the detailed supervision and administration. 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 5 5 1 11 Maternity 20 31 10 61 Domestic 18 19 6 43 Total for year 48 55 17 115 The Care of Illegitimate Children. It may be useful briefly to review our arrangements for the care of illegitimate babies and the Mothers of these babies in our area. Before the war the Wimbledon, Merton and Morden Moral Welfare Association had a home in Wimbledon, the Jane Witts Home, at 56, Gap Road, Wimbledon. This home provided AnteNatal, Maternity and Hostel accommodation for unmarried Mothers and their babies. The field work for our area as well as for Wimbledon was done by an outworker of the Association. In the autumn of 1940, the home was bombed and had to be evacuated, but the outworker continued to deal with cases referred to her and secured hostel accommodation mainly outside London. In October, 1943, as a result of representation by the Ministry to local authorities to review their arrangements in view of the large increase in numbers of these cases, the matter was brought under consideration and after careful examination of the possibilities it was decided to consult the Moral Welfare Association to see whether they were prepared to re-open their home. It was found that they were anxious to do so but their land had meantime been included in a housing scheme and was no longer available. They were, however, so ready to cooperate in resuming this work that they set about searching for premises. 32 At the time of writing this report they have again opened a home, the Haygarth Witts Memorial Home in Wimbledon, and they are preparing plans for adaptation for submission to the Wimbledon Borough Council for registration under the Nursing Homes Registration Act, 1927. Meantime they are taking cases both from Wimbledon and Merton and Morden, who have agreed to pay for these cases on a cost basis. They have not resumed the lying-in accommodation nor do they intend to do so. Sterilised Maternity Outfits. Sterile outfits 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 56 outfits were supplied at cost price. Dental Scheme. There has been a further expansion in the dental work, and there would seem to be opportunities in various directions for further expansion, but this would immediately necessitate additional sessions, and these in their turn present us with our old problem, lack of accommodation. As I have said before earlier dental inspection of expectant mothers is essential. The futility of conservation work when threequarters of pregnancy has already passed should be obvious, and it is general for the first medical inspection in pregnancy to be delayed till five months. It is general for the mother only then to be referred for dental treatment so that before anything can be done she has generally reached six months. It seems essential if conservation work is of any value to secure it earlier than this and cards for dental inspection should be given by whoever first learns of the pregnancy, whether midwife, health visitor or even food officer. 33 TABLE XI. Attendances at Dental Clinics during 1946. Cases referred from— Number who attended during year Number of Attendances made MERTON Mothers 6 26 Children 9 16 Individuals 15 42 MORDEN Mothers 169 455 Children 19 39 Individuals 188 494 RAYNES PARK Mothers 85 229 Children 16 33 Individuals 101 262 GRAND DRIVE Mothers 113 342 Children 20 47 Individuals 133 389 BAPTIST HALL Mothers 11 59 Children 6 8 Individuals 17 67 ALL CENTRES Mothers 384 1.111 Children 70 143 Individuals 454 1,254 The dental operations performed were as follows:— TABLE XII. Dental Scheme 1946—Operations Performed. Extractions—Temporary Teeth 264 Permanent Teeth 1,209 Fillings—Temporary Teeth 72 Permanent Teeth 402 Dentures supplied—Number of cases 82 Number of local anæsthetics given 105 Number of Gases given 415 34 Midwives. One midwife is appointed by the District Council under the Surrey County Council's scheme for a salaried midwifery service. The fees fixed by the County Council are:— As maternity nurse 35/- As midwife 40/- Provision is made for a reduction in the fee in necessitous cases. The following figures indicate the work undertaken during the year by the Council's midwife Cases conducted: Primip. Multip. Total (a) As midwife Live 8 38 46 Still — — — (b) As maternity nurse Live 4 5 9 Still — — — 12 43 55 Visits made: By midwife Ante-natal 436 During confinement 928 To midwife Ante-natal 218 Post-natal 252 1,834 Medical Aid Forms sent:—10 Discharging Eyes 2 Infant Jaundice 1 Infant Ringworm 1 Ringworm (mother) 1 Rupture of Perineum 5 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 are eighteen 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. It is annually a source of gratification to be able to record our indebtedness to our voluntary helpers. They have always been a feature of our clinic organisation, and while from time to time we have moments of acute anxiety as 35 to whether the ranks of the presbytery will be filled when they perforce vacate their offices, up to the present recruits have been forthcoming. So we continue to hope that the fount of public spiritedness to which we are indebted for this help will not dry up. Child Life Protection. Our responsibilities in this regard it seems will shortly cease. It is safe to say as far as the supervision of this group of foster children is concerned, that is to say those required to be notified under Section 206 of the Public Health Act, whose supervision has been made the responsibility of the Welfare Authorities and who come under the supervision of the Health Visitor Inspectorate, that these responsibilities have generally been faithfully and conscientiously carried out. Moreover, their qualifications to carry out this supervision hardly seem to have obtained the notice which they merit. Nor will a change in inspectorate and a transfer of responsibility remedy difficulties inherent in such arrangements. In this particular group, for which we have been responsible, the biggest single factor threatening the child's happiness and proper development is the frequency of change. Our records show, and I have little doubt records of other authorities would also show, a distressing frequency of change of foster-mother within a period of not more than a year. It is still a remarkable fact that the strict letter of the law with regard to notifications is often neglected. The present difficulty in finding foster homes and the belief that too obstrusive inspection may deter suitable women, who would otherwise be willing, from accepting such responsibility, discourages prosecutions for technical offences, merely for the sake of public education. As will be seen from the tabulated statement below, there were 9 foster-mothers and 8 foster children under supervision at the end of the year. During the year 138 visits were paid to registered homes in the district, giving an average of 15 visits per home per year. No children were boarded out in this district under the Public Assistance or other arrangements of the Surrey County Council during the year. The following are the main facts relating to child life protection work during the year:— Registered homes under supervision during the year 18 Registered homes under supervision at end of year 9 New homes registered during the year 9 Children on register at end of year 8 Children brought on to register during year 8 Children removed out of district during year 11 Visits paid to nurse children 138 Number of children who died during year - Number of cases where legal proceedings were taken - 36 Day Nurseries. There were three nurseries in operation during the year, though from the receipt of the Ministry circular, advocating the discouragement of mothers of babies under two from going out to work, and announcing the withdrawal of the full reimbursement, it was decided to convert the Manor House Nursery into a nursery school if the Education authority could be persuaded to take it over. It was, however, continued as a day nursery until the end of the year. The appended figures show the extent of the use of nurseries by the mothers during the year. All efforts to recruit wardens during the year were fruitless. Two of the nurseries were without a warden or teacher for the whole of the year. The seriousness of this disadvantage has been commented on before. At the time of writing this report our last teacher has resigned, so we now have still two nurseries but no teacher in either. 37 TABLE XIII. DAY NURSERIES—AVERAGE DAILY ATTENDANCES, 1946. Nursery Jan. Feb. March April May June July August Sept. Oct. Nov. Dec. High Path. Daily average 35 44 41 48 41 30 42 41 48 52 50 43 Highest daily average 41 48 50 53 50 38 44 52 53 54 54 49 Manor House. Daily average 33 46 55 55 57 52 51 51 54 53 47 37 Highest daily average 42 55 48 51 66 61 61 71 70 63 52 52 Middleton Road. Daily average 42 48 47 37 40 44 47 41 46 42 40 45 Highest daily average 49 53 52 46 54 55 58 55 54 54 44 46 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. 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 investiga tion. 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 analyses 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. No important extensions to sewerage were carried out during the year. Closet Accommodation. All premises have water closets drained to sewers except four which are drained to cesspools. In addition there are four chemical pail closets on Sports Grounds. Public Cleansing. The collection and disposal of house refuse throughout the district is presenting much difficulty because of the shortage of staff. The salvage tonnage for the year under review was as follows:— Tons Tons Paper 241 Bottles and Glass 134 Metals 81 Rags 16½ Pig Food 902 39 REPORT OF THE CHIEF SANITARY INSPECTOR. Mr. Chairman, Ladies and Gentlemen, I beg to submit the Annual Report which summarises the work carried out by your Sanitary Inspectors during the year ended 31st December, 1946. Housing Inspections. The total number of houses inspected during the year for "sanitary defects" under the Public Health and Housing Acts was 495. Action taken in connection with defective dwelling houses is set out in the housing table on pages 47 and 48. Notices specifying the necessary work required to remedy sanitary defects were served upon owners of properties as follows:— Intimation notices 450 Statutory notices:— - Public Health Act, 1936 44 Housing Act, 1936 5 Eradication of Bed Bugs. Twelve houses were found on inspection to be infested with bed bugs, and are classified as follows in accordance with the requirements of the Ministry's Circular:— Council Houses Other Houses Total 4 8 12 Disinfestation was carried out by spraying with insecticides containing D.D.T. Drainage Work. At 12 houses the drainage systems were entirely reconstructed and at 57 houses extensive repairs to drains were carried out. Smoke and water tests were applied to the drains of houses in 61 instances, and obstructions were removed from drains at 114 houses. Food Supply. The total number of inspections made to premises where articles of food are prepared or exposed for sale was 1,219. At 9 premises improvements in sanitary conditions were effected. Unsound Food. The undermentioned articles of food were found, upon inspection, to be unfit for human consumption; were surrendered and either destroyed or disposed of for animal feeding or salvage:— 40 Description and Quantity. Cause. Mutton and Lamb, 65 lbs. Putrefaction and Decomposition Beef, 804½ lbs. Bone Taint, Fibrosis and Decomposition Fish, 107 stone. Unsound and Putrefaction Fish Roe, 4 stone Putrefaction Butter, 6 lbs. Rancid Margarine, 3½ lbs. Rancid Eggs, 277. Decomposition and Unsound Polluted Semolina, 14 lbs. Jam, Marmalade, Honey and Golden Syrup, 19 lbs. Broken Jars and Unsound Pickles, 1 jar Broken Jar Sweets, 36¾ lbs. Mildew and containing glass splinters Irish Rabbits, 60 lbs. Unsound Bovril, 1 jar Broken Jar Cheese Trimmings, 19¾ lbs. Mould Dried Egg Powder, 4 pkts. Unsound and Mould Fish Cakes, 48. Unsound Figs, 9½ lbs. Mould Chicken, 100 lbs. Decomposition Dried Peas, 214 lbs. Weevil and Unsound Sponge Mixture, 60 pkts. Contaminated Cake Flour, 24 pkts. Contaminated Cheese, 12 ozs. Unsound Cornflakes, 1 pkt. Unsound Biscuits, 1 pkt. Unsound Raisins, 2 pkts. Unsound Pea Soup Powder, 8 pkts. Unsound and Contaminated Custard Powder, 1 pkt. Unsound Jelly Crystals, 16 pkts. Unsound Cocoa, 5 pkts. Unsound Prunes, 54½ lbs. Mould Paste, 6 ozs. Unsound Luncheon Beef, 2 lbs. Putrefaction Dates, 25 lbs. Weevil Crumpets, 126 Unsound Pudding Mixture, 6 pkts. Contaminated Australian Eggs, 36 tins Unsound Tinned Meat, Milk, Fish, Vegetables, Fruit, etc. 1,855 tins Pierced, Blown and Unsound 41 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 — — — — 198 Number inspected — — — — 198 Number found fit for human consumption — — — — . 195 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 arrives either by rail or road. 69 inspections were made to dairies and milk shops during 1946. Twenty-four samples of milk were submitted for bacteriological examination during the year and all were reported as satisfactory. Twenty licences were granted to dealers under the Milk (Special Designations) Regulations and were in force at 31st December, 1946. 42 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 1 1 — — Aspro 1 1 — — Bacon 1 1 .— - Baking Powder 2 2 — — Basilicon Ointment 1 1 — - Beer 1 1 - - Black Pudding 1 1 — — Boracic Ointment 1 1 — — Brawn 1 1 - - Bread 1 1 — - Brisling 1 1 — — Brompton Syrup 1 1 — — Butter 2 2 — - Cake Mixture 2 2 — - Chocolate Drops 1 1 — — Coffee 1 1 — — Coffee and Chicory 1 - 1 Retailer's explanation accepted Compound Syrup of Figs 1 1 — — Cremola 1 1 — - Curry Powder 1 1 — — Custard Powder 1 1 — — Epsom Salts 1 1 — — Evaporated Milk 1 1 — — Fish Paste 4 4 — Flavour, Vanilla 1 1 — - Flour, Pea 1 1 - - Flour, Self Raising 3 3 — — Ginger Ale 1 1 — — Gravy Powder 1 1 — — Ground Ginger 1 1 — — Jam 2 2 — - Jardox 1 1 — - Jelly 1 1 — — Junket Powder 1 1 — — Lard 1 1 — - Lemonade 1 1 — — Lemonade Powder 1 1 — - Lemon Curd 1 1 — — Macaroni in Tomato Cheese Sauce 1 1 — - Malt Vinegar 2 - 2 Dispensation from Ministry of Food Malted Milk Tablets 1 1 — — Margarine 3 3 — — Marmite 1 1 — — Carried forward 56 63 3 - 43 Article. Total Samples. Genuine. Not Genuine. Action Taken. Brought forward 56 53 3 — Meat Soup 1 1 - — Medicinal Liquid Paraffin 1 1 — — Milk 28 28 - - Minced Beef 1 1 — - Mint 1 1 - — Mint Sauce 1 1 — — Mixed Spice 2 2 - - Mustard 2 1 1 Legal proceed ings Mustard Cream l 1 — — Pepper, Black l 1 — — Piccalilli l 1 — — Pudding Mixture 3 1 2 Stocks withdrawn Sausages 4 4 - — Sausage Liver 2 2 — — Sausage Meat 3 3 — — Semolina 2 2 — — Shredded Suet 1 1 — — Soda Bicarbonate 1 1 — — Stuffing 1 1 - — Sulphur Ointment 1 1 — — Vegetable Soup 1 1 - — Vi-Cocoa 1 — 1 Stocks withdrawn Virox Cubes 1 1 — — Whisky 1 1 — — Yeast 1 1 — — Zinc Ointment 1 1 - - Total 120 113 7 — 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 — — 6 11 7 3 1 — 28 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 Total - 1 2 6 5 7 4 2 1 — — — 28 44 Factories. The number of inspections made to premises registered under the Factories Act—147. Defects relating to sanitary conveniences, ventilation and other sanitary matters were dealt with at 28 premises. Water Supply. Six samples of water from domestic taps were taken and submitted for chemical or bacteriological examinations. The report on each sample was satisfactory. Water Courses. Seventy-two 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 1,344 visits were made to premises where infestations were known or suspected and 204 premises were cleared. Shops Acts, 1912-1936. The following statement summarises the inspections made, the infringements discovered, and other matters dealt with during the year:— No. of Inspections:—Day Visits 157 Evening Visits - Infringements:— 1. Evening closing hours Nil 2. Half-day closing 1 3. Hours of employment for young persons Nil 4. Seats not provided for females Nil 5. Prescribed notices not correct or exhibited 25 6. Sanitary arrangements unsatisfactory Nil 7. Reasonable temperature not maintained Nil 45 Summary of Sanitary Inspections. Housing—primary visits 495 Re-inspections—work in progress 1,531 Re Overcrowding provision 263 Miscellaneous, housing 179 Drainage work 712 Factories and Workplaces 147 Stables and Piggeries 104 Rats and Mice destruction 1,344 Enquiries, infectious diseases 156 Visits to schools 14 Smoke abatement 10 Food shops, etc. 1,219 Milk supply 69 Rivers and Streams, pollution 72 Complaints investigated 756 Miscellaneous 842 I am, Ladies and Gentlemen, Your obedient Servant, F. C. THOMAS, Chief Sanitary Inspector. August, .1947. 40 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) 495 (b) Number of inspections made for the purpose 495 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 441 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 361 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 5 (ii) Number of dwellinghouses which were rendered fit after service of formal notices:— (a) By owners 4 (b) By local authority in default of owners - 47 B.—Proceedings under Public Health Acts:— (i) Number of dwellinghouses in respect of which notices were served requiring defects to be remedied 44 (ii) Number of dwellinghouses in which defects were remedied after service of formal notices:— (a) By owners 37 (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 40-44). 48 SECTION F—INFECTIOUS ILLNESS Notification. The following diseases are notifiable in the Urban District:— Smallpox. There were no cases of Smallpox during the year in this district. There has, however, been a considerable amount of follow-up work done by the department during the year, keeping persons under observation arriving in this Country by air from abroad, from what are known as smallpox contact areas, that is, areas where smallpox is occurring and though they are not known to be actual contacts of a case, they have had opportunities for such contact. Enteric Fever. There have been no cases of Enteric Fever in the district during the year, nor have there been any such cases for the past four years. From time to time sporadic cases occur without the source being traceable. The last cases we had of this nature were in 1941, and before that we had no cases since 1937, when one case occurred. Dysentery. There has been a welcome drop in the number of cases of Dysentery. This year we have had 6 cases only notified. It should not be forgotten, however, that dysenteric infections are so mild that they do not require the attention of the doctor and among those that are seen by the doctor, many do not justify the label dysentery, so that the dysentery notifications cannot be regarded as an entirely reliable index of the incidence of infection by the dysenteric group of organisms. It is only when severer manifestations occur in an individual or where a group of individuals suffer Cholera Cerebro-Spinal Fever Continued Fever Diphtheria (including membranous Croup) Dysentery Enteric Fever (including paratyphoid fevers) Erysipelas Encephalitis Lethargica Food Poisoning Malaria Ophthalmia Neonatorum Plague Acute Primary Pneumonia Acute Influenzal Pneumonia Acute Poliomyelitis Acute Polio-Encephalitis Puerperal Pyrexia Relapsing Fever Scarlet Fever Smallpox Trench Fever Typhus Fever Tuberculosis (all forms) Whooping Cough Measles 49 ously that they are brought to our notice. There is a great deal of evidence that minor manifestations of infection by these organisms are widespread and frequent. Nor is this to be wondered at when we reflect on the present quality of food hygiene. The present methods of distribution and sale of our food leaves much to be desired. War conditions arrested the progress we had made prior to 1939 in this important health factor and we have not really begun to regain the ground we have lost since that time. We recognise that shortages in many materials necessary effectively to protect our food in distribution are a serious handicap, but we should be on the alert against these excuses being perpetuated and serving to mask the real obstruction, a reluctance to go to the additional trouble and expense involved in providing protective measures. In terms of pounds, shillings and penee even, it may well be that the cost of the consequent sickness is more than would be required to supply the remedy. We are very much behind some other countries in regard to these matters. Scarlet Fever. For the past three years Scarlet Fever has had a fairly constant incidence from about 100 to 130 cases. There were 127 cases in the year 1946, thirteen more than in the previous year. The disease maintains its now characteristic mildness and there is growing doubt as to the need for, or the wisdom of, hospitalisation. One argument put forward for the continuation of the practice of sending these cases to hospital is that the public have come to accept that as the proper procedure, and if we succeeded in persuading them now that it is not necessary or advisable and the character of the disease suddenly changed, as we know it might do, and assumed its old viciousness, we should have to start all over again teaching the need for hospitalisation of this disease. Diphtheria. There were 9 cases of Diphtheria during the year with no deaths. This is only one more than in 1934, when there were 8 cases, the lowest figure ever recorded. Measles. Although 1946 was not properly an epidemic year for measles, there were 568 cases. The disease generally was mild in character and there were no deaths. Whether the freedom from severe complications and permanent damage of present day measles is due to modification of the disease, or improved resistance in the present day child, is a matter for speculation, but the annual incidence of such a large number of cases must improve the herd immunity of our child population. Whooping Cough. During the year this disease assumed epidemic proportions and the cases totalled 238. This is the highest number since 1943. Happily the local mortality from 60 this disease was nil. It is a remarkable fact that the two diseases, whooping cough and measles, which used to be so much feared in their epidemic form, now carry so little risk to life. One does not however forget the distressing discomfort attended upon the disease in children, nor its debilitating effect. Anterior Poliomyelitis. There were two cases of acute Anterior Poliomyelitis during the year and no deaths. One case was in an infant of seven months and the other in a school child of nine years. Both these cases were treated in the Wandle Valley Hospital where arrangements are made from the earliest stage for supervision of orthopaedic treatment by a Specialist, and attendance at the physiotherapeutic department of their nearest hospital as soon as they can be discharged from hospital. Cerebro-Spinal Fever. There were two cases notified as Cerebro-Spinal Fever in infants. Both were treated in the St. Helier County Hospital and each recovered without any sequelæ. Erysipelas. There were ten cases of Erysipelas notified during the year of which eight involved the face, one of the foot and one of the legs. Six occurred in males and four in females. All the cases occurred during the winter months. Food Poisoning. No case of food poisoning was notified during the year. Ophthalmia Neonatorum. Notification of six eases was received during the year. Four were hospital cases and the treatment was carried out throughout in hospital. There was no impairment of vision in any of these cases. It is perhaps worth noting that the treatment and prognosis of these cases has been revolutionised by the discovery of Penicillin and their claim to administrative anxiety is, in consequence, correspondingly lessened. Pneumonia. There were 70 cases of Pneumonia, of which 28 were stated to be influenzal in origin. There were 71 cases notified in the previous year. Puerperal Pyrexia. There were 10 notifications of Puerperal Pyrexia, giving a rate of 7.7 per thousand total births. Of the 10 cases 8 occurred in hospitals and 2 at home. Treatment of these cases is now undertaken by the Wandle Valley Hospital and during the year 3 of the cases were admitted for treatment. CLEANSING STATION. As will be seen from the appended table 798 attendances were made at the Cleansing Station. This figure compares with 1,222 attendances in 1945. 61 Number of cases of Scabies treated 366 Cases of Scabies with concurrent verminous head 2 Cases of Scabies with Secondary Septic Skin condition 25 Number of cases of Verminous heads only 183 Total number of attendances at the Centre 798 TABLE XIV Scarlet Fever—Monthly Distribution. Wards. Abbey. Bushey Mead. Central. Morden. Park. Ravensbury. Raynee Park. St. HeLier. West Barnes. Total. January - 2 5 3 2 1 - 2 - 15 February 1 1 3 1 — 4 — — 2 12 March — 2 — 1 — - 1 1 — 7 April — 2 4 7 3 1 - — 1 18 May — 2 2 3 3 2 - 1 — 13 June — 2 1 6 1 2 - — — 12 July — — 2 9 — — — — — 11 August — 1 — — — — - — — 1 September 2 1 — 3 — 1 - - — 7 October - - 2 9 2 1 - - 2 16 November - 1 1 4 - - - 1 1 8 December — - - 2 1 3 — 1 - 7 Total 3 14 20 48 12 17 1 6 6 127 Monthly mean 0.25 1.16 1.66 4.0 1.0 1.41 0.08 0.5 0.5 10 58 The incidence in the various wards was as follows:— Wards. Cases. Incidence per 1,000 population. Abbey 3 0.5 Bushey Mead 14 1.7 Central 20 1.7 Morden 48 4.1 Park 12 1.1 Bavensbury 17 2.4 Raynes Park 1 0.1 St. Helier 6 0.5 West Barnes 6 0.8 52 TABLE XV. Infectious Diseases, Notifications, Deaths and Distribution, 1946. Disease Cases Notified Case Rate per 1,000 population Deaths among notified cases Percentage of deaths to cases Distribution of Cases Wards No. of cases removed to hospital Percentage of cases removed to hospital Abbey Bushy Mead Central Morden Park Ravensbury Raynes Park St. Helier West Barnes Smallpox - - - - - - - - - - - - - - - Scarlet Fever 127 1.72 - - 3 14 20 48 12 17 1 6 6 103 81% Diphtheria 9 0.12 - - - - 2 — 1 — 3 2 1 9 100% Enteric Fever - - - - - - - - - - - - - - - Cerebro-Spinal Meningitis 2 0.02 - - - - - 2 1 - - - - 2 100% Puerperal Pyrexia 10 0.13 - - - 2 1 1 6 - - - - 8 80% Erysipelas 10 0.13 - - 1 1 1 — 3 1 1 2 — 4 40%' Pneumonia 42 0.57 1 2 1 5 6 6 11 4 1 7 1 — *- Poliomyelitis 2 0.02 - - - - - - - 1 - - 1 2 100% Relapsing F ever - - - - - - - - - - - - - - - Typhus Fever - - - - - - - - - - - - - - - Dysentry 6 0.08 - - 3 2 1 - - - - - - - - Encephalitis Lethargica - - - - - - - - - - - - - - - Ophthalmia Neonatorum . 6 0.08 - - 1 - 1 1 3 - - - - 2 33%' Plague - - - - - - - - - - - - - - - -Malaria 1 0.01 - - - - 1 - - - - - - - - Influenzal Pneumonia . 28 0.38 1 3% 3 - 4 7 8 4 - 2 - - * Measles 535 7.27 - - 30 27 97 115 81 31 30 100 24 3 0.5% Whooping Cough 238 3.23 - - 23 8 49 39 17 28 22 45 7 2 0.8% *Number admitted to isolation hospital only. 63 TABLE XVI. Notification of Infectious Diseases (other than Tuberculosis) by Age Groups during the year 1946. Disease TOTAL CASES NOTIFIED. Total Cases at all Ages Under 1 yr. 1-2 2-3 3-4 4-5 5-10 10-15 15-25 25-35 35-45 45-65 65 and over Smallpox — — — — — — — — — — — — — Scarlet Fever — 1 5 6 5 70 26 6 2 6 — — 127 Diphtheria (including Membranous Croup) — — 1 — — 2 2 3 — 1 — — 9 Enteric Fever (including Paratyphoid) — — — — — — — — — — — — — Puerperal Pyrexia — — — — — — — 1 8 1 — — 10 Acute Primary Pneumonia 4 3 1 — — 7 1 5 2 3 11 5 42 Acute Influenzal Pneumonia 1 2 — —. — 2 1 4 5 3 6 4 28 Cerebro-S pinal Meningitis 1 1 — — — — — — — — — — 2 Poliomyelitis 1 — — — — 1 — — — —— — — 2 Acute Polio-Encephalitis — — — — — — — — — — — — — Encephalitis Lethargica — — — — — — — — — — — —— - Dysentery — — — — 1 3 —— — — 2 — — 6 Malaria — — — — — — — — 1 — — — 1 Ophthalmia Neonatorum 6 — — — — — — — — — — — 6 Erysipelas — — — — — — — — — 1 7 2 10 Plague — — — — — — —— — — — — — — Relapsing Fever — — — — — — — — Typhus Fever — — — -— — — — — — — — — — Measles 17 53 66 63 76 239 10 3 2 3 3 — 535 Whooping Cough 20 16 38 41 36 79 8 3 1 1 — — 238 Totals 50 76 111 110 118 403 43 25 21 21 27 11 1016 54 TABLE XVII. Monthly Incidence of Infectious Disease, 1946. Disease. January February March April May June July August September October November December Totals Smallpox - - - - - - - - - - - - - Scarlet Fever 15 12 7 18 13 12 11 1 7 16 8 7 127 Diphtheria - - 4 1 1 - - - - - - 3 9 Dysentery - - - - - 0 - - 1 - - - 6 Enteric Fever - - - - - - - - - - - - - Cerebro-Spinal Meningitis - 1 - - - 1 - - - - - - 2 Pneumonia 5 9 o 4 - 3 1 - 2 3 5 5 42 Influenzal Pneumonia 6 11 1 2 - 1 - - - - 5 2 28 Erysipelas 1 1 2 - - - - 1 2 - 1 2 10 T.B. Pulmonary 4 2 9 4 14 5 5 7 7 6 4 6 73 T.B. Non-Pulmonary - 1 1 1 1 - 3 1 1 1 - 2 12 Ophthalmia Neonatorum 1 1 - - - - 2 1 1 - - - 6 Puerperal Pyrexia Poliomyelitis 1 1 - 1 1 1 2 3 - - - - 10 Encephalitis - 1 - - - - - 1 - - - - 2 argica - - - - - - - - - - - - - Malaria - - - 1 - - - - - - - - 1 Measles 6 2 41 107 77 144 76 28 10 4 3 37 535 Whooping Cough 3 6 8 28 20 40 39 17 20 21 20 16 238 Totals 42 48 78 167 127 212 139 60 51 51 46 80 1,101 55 DIPHTHERIA IMMUNISATION. There were 674 children under five immunised in the clinics during the year, 62 done by private practitioners under the Council's scheme and 34 done in the day nurseries, making a total of 770 under fives. Of the school age group there were 52 done in the clinics, 10 by private medical practitioners and 568 done in the schools. Reinforcing or booster doses were given to 8 under five and 75 school children in the clinics and 1,456 over five in the schools. The figures of children done in school include some children from other districts attending schools in our area. There were no children immunised at less than 11 months of age, but 75 were immunised at 11 months. It is very noticeable that a very high proportion of these first injections are done close to the first birthday, showing that our educational efforts to get immunisation done at 1 year have borne fruit. We are now making similar efforts to get immunisation done at 7—8 months, and if we are as successful as these figures seem to show with regard to our previous education, we should find next year a far greater iramber under 1 year and a high proportion of them at earlier ages than 11 months. At the end of last year the responsibility for immunisation was placed on all Welfare Authorities by thS Ministry of Health. This made no change as far as we were concerned except to adopt a new system of record cards. As there has been no death in an immunised child under 15, there has been no need to comply with the direction to report specially on such an incident. TABLE XVIII Persons Immunised at Clinics during 1946. Wards. Age Groups. I Total. 0—5 yrs. 5—15 yrs. Completed Primary. Single Boosting Injections. Completed Primary Single Boosting Injectious. Completed Primarv. Single Boosting Injections. Abbey 51 1 2 7 53 8 Bushey Mead 69 — 5 4 74 4 Central 110 1 9 16 119 17 Morden 132 1 11 14 143 15 Park 56 1 5 14 61 15 Ravensbury 63 1 5 4 68 S Raynes Park 47 1 5 6 52 7 St. Helier ... 81 2 7 1 88 3 West Barnes 65 — 3 7 68 7 674 8 5 i 73 726 81 56 TABLE XIX 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 2 - - - 2 - Bushey Mead 1 - - - 1 - Central 11 - 1 - 12 - Morden 6 .— 1 - 7 - Park 11 — 2 - 13 - Ravensbury 17 - - 1 17 1 Raynes Park 2 - 2 - 4 - St. Helier 7 — — — 7 - West Barnes 5 — 4 — 9 - 62 10 1 72 1 TABLE XX. Children Immunised in Schools. School Incomplete. Completed Primary. Single Boosting Injections. Bushey County Primary 4 29 133 Poplar Road Primary 3 57 136 St. Mary's „ 2 90 72 Merton Abbey ,, 6 39 97 Hillcross ,, 1 48 243 Raynes Park 6 51 54 Morden ,, 1 39 86 Morden Farm ,, 6 74 222 St. Helier No. 1 ,, 6 8 50 St Helier No. 2 ,, 5 13 37 St. Helier No. 8 ,, — 49 75 St. Helier No. 4„ 3 13 45 Holy Family R.C. Voluntary Primary 3 24 88 Sacred Heart R. G. Voluntaty Primary 6 34 118 52 568* 1,456* * Includes children attending schools in Merton and Morden but resident in other areas:— Primary 80 Boosting 210 290 57 TABLE XXI. Children Immunised in Day Nurseries. Nursery Complete Middleton Road 5 Manor House 10 High Path 19 34 The number immunised since the inauguration of the Public Clinics in 1934 is as follows:— At By In At Day Clinics. Doctors. Schools. Nurseries. Total. 1934 93 28 - - 121 1935 375 19 — — 394 1936 383 13 664 — 1,060 1937 502 27 293 — 822 1938 376 22 260 — 658 1939 277 11 303 — 591 1940 234 12 50 — 296 1941 700 6 3,198 — 3,904 1942 1,127 16 753 — 1,896 1943 813 64 211 51 1,139 1944 515 54 216 28 813 1945 806 91 105 33 1.035 1946 726 72 488 34 1,320 TABLE XXII. Incidence and Fatality of Diphtheria, 1920-1946. Year. Population. No. of cases. Incidence rate per 1,000 population. No. of deaths. Percentage of deaths to cases. 1920 18,200 47 2.5 3 6.3 1921 18,000 28 1.5 1 3.5 1922 18,500 62 3.3 4 6.4 1923 18,750 39 2.08 1 2.5 1924 18,710 68 3.6 6 8.9 1925 18,960 25 1.3 1 8.3 1926 19,980 24 1.2 2 8.5 1927 21.850 29 1.3 2 6.8 1928 25,780 38 1.4 — — 1929 27,430 53 1.9 1 1.8 1930 35,000 72 2.05 6 8.3 1931 41,610 80 1.9 6 7.5 1932 48,550 30 0.6 — - 1933 52,130 35 0.6 1 2.8 1934 55,550 82 1.4 8 9.7 1935 57,440 44 0.76 4 9.0 1936 61,000 28 0 45 — - 1937 65,530 22 0.33 4 18.1 1938 68,980 28 0.40 2 7.1 1939 71,220 32 0.44 2 6.2 1940 68,540 20 0.29 1 5.0 1941 64,920 24 0.36 — - 1942 66,590 15 0.22 1 6.6 1943 65,880 16 0.24 1 6.35 1944 62,760 3 0.12 4 12.5 1945 f-6,050 12 0.18 1 8.3 1946 73,590 9 0.12 58 TABLE XXIII. Diphtheria Immunisation. Number of children 0— 5 years immunised January—June, 1946 392 „5-15„ 72 ,, ,, 0— 5 ,, ,, July—December, 1946 405 „ 5- 15 2 451 Total number of children 0— 5 years immunised during the year 1946 797 „5-15„ 523 Number of children 0— 5 years immunised by Private Practitioners during the year 1946 62 „5-15„ 10 Total number of children immunised by Private Practitioners during the year 1946 72 Total number of children immunised in the Clinics during the year 1946 ... 726 Total number of children immunised in the Day Nurseries during the year 1946 ... 34 Estimated percentage of 0— 5 years immunised at end of year 1946 ... 49.3 „5-15„ 74.6 Age Distribution of Immunised Children. Age at 31.12.46 i.e., born in year Under 1 1946 1 1945 2 1944 3 1943 4 1942 5 to 9 1937—1941 10 to 14 1932-1936 Total Immunised Estimated Population 0-5 Estimated Population 5-15 Total Population up to 15 Number Immunised Nil 559 793 603 590 3,851 3,284 9,680 5.160 9,560 14.720 59 TUBERCULOSIS. One hundred and nineteen new eases were added to the register of tuberculous persons. compared with 139 in 1945. These additions were:— Males Females Total Pulmonary 61 40 101 Non-Pulmonary 9 9 18 70 49 119 Of these 119, 85 were primary notifications, 27 were transferred from other districts, and 7 came to notice in other ways. During the year 98 persons were removed from the register for the following reasons:— Recovered 17 Removed from the district 44 Death 37 After allowing for the additions and deductions, the number remaining on the register at the 31st December, 1946, was distributed as shown in the following table:— TABLE XXIV. Tuberculosis Register at 31st December, 1946. Wards. Registered at 31st December, 1946. Total. Number on Register at mid-year. Pulmonary. NonPulmonary Abbey 43 9 52 53 Bushey Mead 65 15 80 83 Central 50 11 61 62 Morden 86 14 100 104 Park 97 20 117 115 Ravensbury 94 25 119 116 Raynes Park 62 5 67 63 St. Helier 128 31 159 150 West Barnes 46 17 63 63 Whole district 671 147 818 809 The Anti-Tuberculosis Scheme in this district is administered by the County Council. Institutional treatment was 60 provided for 81 persons in 1946 from Merton and Morden, as follows:— At the County Sanatorium, Milford 17 At other Institutions 64 81 The deaths from Tuberculosis number 43, of which 37 were due to pulmonary and 6 to non-pulmonary disease. The deaths are classified by age and sex in the following table:— TABLE XXV. Deaths due to Tuberculosis, 1946. Ages Years Pulmonary Non-Pulmonary Totals Males Females Males Females 0— 1 - - - 1 I — — — 2 — 2 5— - - - - - 15— 1 3 1 2 7 25— 4 5 — — 9 35— 4 2 — 1 7 45— 6 1 — — 7 55— 4 2 — — 6 65— 3 1 — — 4 Totals 23 14 3 8 43 Ten deaths were in unnotified cases. The district provides a free service for the examination of sputum for tubercle bacilli. During the year 45 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. Tuberculosis Care Committee. This year for the first time one Committee deals with the whole of Merton and Morden. There are obvious advantages in this arrangement. The functions of these Care Committees and the value of their work is probably not sufficiently widely understood or properly 61 appreciated. They assist the families of the T.B. person in many ways—financially, by mobilising existing agencies, rather than directly, extra nourishment or allowances in kind, by providing or lending beds, bedding; clothing and household articles; domestic help; helping to obtain suitable employment; occupational therapy and rehabilitation; holiday schemes for children in the family; facilitating the examination of contacts with special regard to mass radiography, etc. Appended is a brief report on the work of the local Committee supplied by the Secretary. Assistance given during- 1946. In 20 instances patients were assisted, with the help of the W.V.S., the S.S. & A.F.A. and the B.R.C.S., to obtain bedsteads, mattresses and bedding. Grants were made in 15 cases to enable patients, or their dependents, to secure clothing. 11 patients have received help with fares and 9 have also received pocket money allowance when in Sanatoria. Help has also been given in the following ways:— Part cost of spectacles. Cost of gas-fire in bedroom. Fees for correspondence course and books. Part cost of convalescent treatment. Christmas parcel for patient. Arrears of National Health Insurance. Rent Arrears. In addition to the above, the Committee agreed to purchase a shed to enable a patient unfit for normal work to do carpentry in his own garden. 62 TABLE XXVI. 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 cases. Pulmonary. Non-Pulmonary. Pulmonary. Non-Pulmonary. P.ulmonary. Non-Pulmonary. M F M P M F M F M F M F 0-1 - - - 1 - - - - 1 - - - 2 1-5 1 1 1 - 1 - - - - - 1 — 5 5-10 1 - - 2 - - - - - - - — 3 10-15 - - - 1 - - - - - - - - 1 15-211 8 8 1 1 1 - - - - - - - 19 20-25 5 8 - - 3 3 1 1 - - - - 21 25-35 11 5 2 1 li 5 1 - - 1 - - 32 35-45 8 3 1 1 1 3 - - 1 - - - 18 45-55 5 2 - - - - - - - 1 - — 8 55-65 4 - - 1 - - 1 - 1 - - - 7 65 up 2 - - - - - - - - - - - 3 Totals 45 27 5 8 12 11 3 1 3 3 1 119 85 27 7 63 INDEX PAGE Acreage 8 Ambulance Facilities 21 Acute Poliomyelitis 51 Births 6,8-12,26 Institutional and Domiciliary 10-11 Rates 6-8,12 Bed Bugs—Eradication of 40 Cancer—Deaths from 8,13-15 Rate 8,14 Cerebro-Spinal Fever 51 Child Life Protection 36 Clinics and Treatment Centres 22-23,29 Climatic Conditions 6 Closet Accommodation 39 Cleansing Facilities 51-52 Deaths 6-9,12 Causes of 13-15 Rates 6-9,12 Diphtheria 50 Immunisation 56-59 By age groups 59 Children Immunised in Day Nurseries 58 Children Immunised in Schools 57 Persons Immunised in Clinics 56 Persons Immunised by Private Practitioners 57 Incidence and fatality for 27 years 58 Disinfestation 40 Drainage and Sewerage 39 Drainage work 40 Dysentery 49-50 Enteric Fever 49 Erysipelas 51 64 IN D E X—continued. PAGE Factories 45 Food and Drugs Act, 1938 43-44 Food Poisoning 51 Food Supply 40 Inspections 40-41 Unsound Food 40-41 Health Services 20 Heart Disease—Deaths from 13,15 Hospitals 23-25 Housing 47-48 Inspections and Defects 40,47 Number inhabited 5 Verminous premises 40 Industry 5 Infant Mortality 6,16-18 Causes of death 17-18 Rates 7-8,16-17 Infectious diseases 21, 23-24, 49-51 Diseases notifiable 49 Monthly Incidence 55 Notification by Age Groups 54 Notifications, deaths and distribution 53 Inquests 13 Isolation Hospital 23-24 Laboratory Facilities 20 Examination of clinical material 20 Maternal Mortality 15-16 Rates 8; 16 Maternity and Child Welfare 26 Ante-Natal Clinics 27, 30 Attendances at each Centre by age groups 28 Attendances at Infant Consultation Clinics 28 Attendances at Maternity Clinics 27 Attendances at all Infant Welfare Centres 28 65 IN D E X—continued. PAGE Maternity and Child Welfare continued— Attendances at Centres over last ten years 28 Attendances in relation to the registered births 29 Committee 3 Consultant advice for maternity 31 Convalescent Home Treatment 31 Day Nurseries 37 Attendances 38 Dental Scheme 33 Attendances 34 Operations performed 34 Emergency Maternity Unit 31 Health Visiting 30-31 Home Helps 31-32 Hospital provision for maternity 24—25, 31 Illegitimate children 7,32-33 Midwives 35 Neo-Natal deaths 17-18 Orthopaedic Treatment 31 Premature Births 18-19 Sessions, times and places 22 Sterilised Maternity Outfits 33 Voluntary Helpers 35-36 Work of the Centres 26 Meat Inspection 42 Measles 50 Milk Supply 42 Mosquitoes 45 Nelson Hospital 24—25,29-30 Notification of Births 26 Nursing in the Home 20 Ophthalmia Neonatorum 51 Population 8,10 Pneumonia 51 Public Assistance 5 Public Cleansing 51-52 66 INDEX—continued. Page Public Health Committee 3 Puerperal Pyrexia 51 Rainfall 6 Rateable value 5 Rats and Mice Destruction 45 Respiratory diseases—deaths from 14 Representatives on:— Nelson Hospital Council 3 Tuberculosis Care Committee 3 Wandle Valley Joint Hospital Board 3 Wandle Valley Joint Sewerage Board 3 Road Accidents (deaths from) . 13,15 Sanitary Circumstance 39 Sanitary Inspection 46 Scarlet Fever 50 Incidence in each Ward with rates 52 Monthly distribution of cases 52 School Clinics 22 Shops Acts, 1912-1936 45 Slaughterhouses 42 Smallpox 23,49 Smoke Abatement 46 Social Conditions of the Area 5 Staff 4 Statistics 5-8 Comparative 9 Tuberculosis 25,60-63 Admissions to Sanatorium 25,60 Assistance given 62 Care Committee 3 Deaths due to 61 Dispensary 23 New cases—by age groups 63 Number on register at year end 60 67 I N D E X—continued. Page Venereal Diseases 23 Water Courses 45 Water Supply 39,45 Whooping Cough 50-51 Zymotic Disease—Deaths from 8 Rate 8 68 J. B. 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