MER 11 LIBRARY URBAN DISTRICT of MERTON AND MORDEN ANNUAL REPORT of the Medical Officer of Health for the year 1949 AND REPORT OF THE SANITARY INSPECTOR URBAN DISTRICT of MERTON AND MORDEN ANNUAL REPORT of the Medical Officer of Health for the year 1949 AND REPORT OF THE SANITARY INSPECTOR PREFACE. To the Chairman and Members of the Merton and Morden Urban District Council. Mr. Chairman, Ladies and Gentlemen, I have the honour to present my Annual Report for 1949. Once more I am able to report to you that the health of the district as judged by all standards of measurement known to us compares most favourably with the country as a whole as with the towns both great and small. These comparisons are dealt with in detail in the text of the report. Study of the vital statistics enables us to measure the health of a community, and a comparison with past years gives the clue to trends. The expectation of life at birth in England today is 65 years. What are the possibilities for improvement ? Detailed analyses of causes of death in age groups have been made this year to afford material to form some judgment on these interesting questions. Vital statistics, too, give us only a limited insight into the happiness and well-being of a community; the incidence of mental disease and the prevalence of suicide are our only statistical measure. The available information has been collated and presented in the report. In the detailed analysis of causes of death in age groups it will be of interest that 19 of our residents last year survived their 90th year and that a further five had passed their 95th year. The presentation of this report enables me to record my appreciation of the unfailing interest and encouragement that the Council accords to the Health Department, and also affords me the opportunity of expressing my gratitude to the staff of the department for their loyal support and co-operation. I am, Mr. Chairman, Ladies and Gentlemen, Your obedient servant, A. W. JOHNS, Medical Officer of Health. September. 1950. 3 URBAN DISTRICT COUNCIL OF MERTON AND MORDEN 1949. PUBLIC HEALTH COMMITTEE Chairman: Mr. F. J. Matthews. Mrs. H. Cobbett, J.P., C.C. Dr. E. H. Kelly, J.P. Mr. F. E. Kempsell. Mrs. E. L. Kimber. Mrs. S. A. Lodge. Mr. E. W. Warren. Mr. J. C. Hudson (ex-officio). Mr. S. C. A. Miller (ex-officio). REPRESENTATIVES ON NORTH-EASTERN DIVISIONAL HEALTH SUB-COMMITTEE Mrs. L. A. Doel. Dr. E. H. Kelly, J.P. Mrs. E. L. Kimber. Mr. F. J. Matthews. Mr. E. W. Warren. REPRESENTATIVES ON THE WANDLE VALLEY JOINT SEWERAGE BOARD Mr. S. W. Billingham, J.P. Mr. A. T. Piner. Mr. D. Shadbolt. Mr. J. C. Hudson (ex-officio). MERTON AND MORDEN TUBERCULOSIS CARE COMMITTEE Chairman: Mrs. H. Cobbett, J.P., C.C. Vice-Chairman: Mrs. M. E. Shaw. Secretary: Miss M. P. Morriss. Treasurer: Mr. F. S. Buck. 4 PUBLIC HEALTH STAFF, 1949. Medical Officer of Health: A. Wallace Johns, M.R.C.S., L.R.C.P., D.P.H. Chief Sanitary Inspector: a c d F. C. Thomas, M.R.San.I. Deputy Chief Sanitary Inspector: beef W. T. Pinches, M.R.San.I. Sanitary Inspectors : beef G. E. Maton (From 21-2-49). be E. Kipping (From 17-10-49). b L. H. Thomas. Temporary Assistant Sanitary Inspector: b C. L. Connor (To 7-8-49). Chief Clerk: A. A. Makepeace. Clerks: R. A. Conolly. H. J. Herbert. Miss E. M. Hyem (To 21-6-49). Miss D. Martyn (From 2-8-49). R. J. Mitton (To 12-2-49). F. H. White (From 1-4-49). a Sanitary Inspector's Certificate, Royal Sanitary Institute. b Sanitary Inspector's Certificate, San. Insp. Exam. Joint Board. c Meat and Food Inspector's Certificate, Royal Sanitary Institute. d Sanitary Science Certificate, University of Liverpool. e Smoke Inspector's Certificate, Royal Sanitary Institute. f Sanitary Science Certificate, Royal Sanitary Institute. 5 SECTION A. STATISTICS AND SOCIAL CONDITIONS OF THE AREA. Area (in acres) 3,238 Number of inhabited houses according to Rate Books 22,005 Rateable value at 31st December, 1949 £669,522 Sum represented by Id. rate £2,732 The Urban District of Merton and Morden dates from the amalgamation of Merton with Morden in 1913. The area is both residential and industrial. Its proximity to London and the railway facilities predestined it to be a large dormitory area, and its industrial development, due at first to the River Wandle which, from very early times attracted manufactories depending on such a natural advantage and at a later date to careful and deliberate planning, provided convenient sites for the industrial expansion which was taking place in London. It is appropriate here to record that the River Wandle, to which Merton owes its existence, is under threat of extinction. Ironically enough the "clear rivulet so full of trouts," of Camden's Britannia, is now to a large extent dependent on the sewage effluent from the Croydon Sewage Works for maintaining both its flow and its quality, and the present project to divert this water for cooling purposes for the new Croydon Electric Power Station if carried out must inevitably add to the present difficulty in keeping it free from nuisance. The Merton Board Mills, anxious to preserve the quantity for their industrial use, have unsuccessfully sought to prevent the withdrawal of this water but the riparian authorities and the sanitary authorities appear to have no power to restrain this action. Industry. There were 195 factories registered under the Factory Act at the end of the year, as follows: — Factories with mechanical power:— Employing more than 40 persons 52 Employing less than 40 persons 122 Factories without mechanical power 21 195 Of fifty-two factories employing more than 40 persons, one factory employs more than 2,000, three others employ 500 or more, and a further twenty-seven factories employ more than 100 persons. 6 Climatic Conditions. Rain gauges are installed at the Joseph Hood Recreation Ground and West Barnes Pumping Station. The monthly recordings are as shown below: — RAINFALL, 1949. MONTH JOSEPH HOOD RECREATION GROUND WEST BARNES PUMPING STATION Inches Days with 0.01in. or more Days with 0.04in. or more Inches Days with 0.01in. or more Days with 0.04in. or more January .96 12 7 1.21 14 7 February .89 9 6 1.06 12 7 March .83 6 4 .91 5 4 April 1.70 8 7 1.87 9 7 May 2.11 15 10 2.24 16 10 June .62 5 3 .68 5 4 July 1.65 8 5 1.24 8 5 August 1.21 7 6 1.24 5 4 September .62 9 6 .59 8 6 October 5.57 14 13 5.72 16 14 November 2.27 18 13 2.42 20 14 December 1.33 20 8 1.55 21 9 Total 19.76 131 88 20.73 139 91 VITAL STATISTICS. The summary of vital statistics on page 8 shows two salient features, a decrease in the number of births and an increase in the number of deaths over last year, with the resulting lowest natural increase for 9 years. Our birth rate is now 13.05 compared with 14.45 last year, and our death rate 8.98 compared with 7.6 last year. It is some consolation to know that this is not a local phenomenon, the birth and death rates for England and Wales, London, the 126 great and the 148 smaller towns, given in Table I of Comparative Statistics, also show the same change. It is gratifying to turn to those rates over which we have more control. Our infant mortality rate at 24.36, our maternal mortality rate at nil, our stillbirth rate at 0.27, and our infant death rate from enteritis and diarrhoea at nil are by a considerable margin the most favourable shown in the table. With the exception of Scarlet Fever, Whooping Cough and Measles our infectious disease rate is also more favourable than any available for comparison. I have mentioned in the section on Infectious Disease that the explanation of the higher rate for these three diseases is to be found in the fact that doctors are not always called in for these conditions but that here a greater proportion of parents seek medical advice and in consequence we get a higher notification rate. 7 SUMMARY OF VITAL STATISTICS. (Registrar General's Figures). Population: Registrar General's Estimate 75,470 Births: M. F. Total Live (Legitimate) 503 445 948 (Illegitimate) 20 17 37 523 462 985 Stillbirths (Legitimate 6 8 14 (Illegitimate) — — — 6 8 14 Total Births 529 470 999 Birth Rate 13.05 per 1,000 population Still Birth Rate 14.01 per 1,000 births Deaths: M. F. Total Total Deaths 358 320 678 Death Rate 8.98 per 1,000 population Infant Mortality : Total deaths under one year 24 Infant Mortality Rate per 1,000 Live Births 24.36 Deaths of Legitimate Infants under 1 year 24 Death Rate per 1,000 Legitimate Births 25.31 Deaths of Illegitimate Infants under 1 year — Death Rate per 1,000 Illegitimate Births — Maternal Mortality: Deaths from Sepsis Nil Deaths from other maternal causes Nil Maternal Death rate per 1,000 Live Births Nil Zymotic Deaths: Deaths from Measles Nil Whooping Cough Nil Diarrhoea (under 2 years) Nil 7 Principal Zymotic Diseases 1 Zymotic Death Rate (per 1,000 population) 0.01 Deaths from Tuberculosis: All forms 30 Rate per 1,000 population 0.39 Phthisis: 24 Rate per 1,000 population 0.31 Deaths from Cancer: 152 Rate per 1,000 population 2.01 8 TABLE I. COMPARATIVE STATISTICS, 1949. (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 Administrafive County Merton and Morden Births: Rates per 1,000 Population. Live 16.7 * 18.7 18.0 18.5 13.05 Still 0.39* 0.47 0.40 0.37 0.18 Deaths: All causes 11.7 12.5 11.6 12.2 8.98 Typhoid and Paratyphoid fevers 0.00 0.00 0.00 0.00 0.01 Whooping Cough 0.01 0.02 0.01 0.01 0.00 Diphtheria 0.00 0.00 0.00 0.00 0.00 Tuberculosis 0.45 0.52 0.42 0.52 0.39 Influenza 0.15 0.15 0.14 0.11 0.13 Smallpox 0.00 0.00 — — — Acute Poliomyelitis and Polioencephalitis 0.01 0.02 0.02 0.01 0.01 Pneumonia 0.51 0.56 0.49 0.59 0.31 Notifications: (Corrected) Typhoid Fever 0.01 0.01 0.01 0.01 0.00 Paratyphoid Fever 0.01 0.02 0.01 0.01 0.00 Cerebro-spinal Fever 0.02 0.03 0.02 0.02 0.01 Scarlet Fever 1.63 1.72 1.83 1.46 2.49 Whooping Cough 2.39 2.44 2.39 1.70 4.38 Diphtheria 0.04 0.05 0.04 0.07 0.02 Erysipelas 0.19 0.20 0.19 0.17 0.15 Smallpox 0 00 0.00 0.00 0.00 0.00 Measles 8.95 8.91 9.18 8.54 9.55 Pneumonia 0.80 0.91 0.65 0.55 0.98 Acute Poliomyelitis 0.13 0.13 0.12 0.18 0.13 Acute Polioencephalitis 0.01 0.01 0.02 0.01 0.02 Food Poisoning 0.14 0.16 0.14 0.19 0.11 Rates per 1,000 Live Births. Deaths: AH causes under 1 year of age 32† 37 30 29 24.36 Enteritis and Diarrhoea under 2 years of age 3.0 3.8 2.4 1.7 0.00 Rates per 1,000 Total Births (Live and Still). Notifications: (Corrected) Puerperal Fever and Pyrexia 6.31 8.14 5.30 6.82 5.00 * Rates per 1,000 Total Population, † Per 1,000 Related Births. 9 POPULATION. The Registrar General's figure for our population for the mid-year 1949 is 75,470. This is the highest figure ever recorded for the area. Last year the Registrar General had estimated that our population had dropped by 70 from the 1947 figure of 75,290, which was the previous highest. At the time of writing this it has been announced that we are to have a census in 1951. It will be remembered that the last census was in 1931. It will be of great assistance to have up-to-date factual data once more as methods of estimation, however accurate, can never be absolutely precise. Moreover, it will afford the opportunity of obtaining a considerable amount of information of value to those engaged in social medicine. BIRTHS. There were 985 registered live births in 1949. This is the lowest figure recorded since 1941. The birth rate at 13.05 is the lowest recorded since 1937. This year's number of births is 102 less than last year, and last year's figure was 258 below the previous year; so that in the past two years, from our 1947 record figure of 1,345 our number of births has fallen by 360. There were 14 stillbirths, making a total of 999 births. There were 37 illegitimate births, all of which were live births. This gives an illegitimate birth rate of 37.5 per thousand. The appended table shows the comparison since 1937:— Year No. illegimate live births Rate per thousand live births 1937 21 25.9 1938 31 31.3 1939 27 26.9 1940 29 29.9 1941 40 47.2 1942 39 36.5 1943 57 49.7 1944 49 42.6 1945 63 61.3 1946 45 35.7 1947 38 28.3 1948 42 38.6 1949 37 37.5 10 INSTITUTIONAL AND DOMICILIARY BIRTHS. The notifications show that 842 births took place in institutions, hospitals and private nursing homes. This is 13 less than 1948 and represents 83.2 per cent of the total, as compared with 77.1 per cent for the previous year. These births occurred in the following hospitals and institutions:— St. Helier Hospital 438 Nelson Hospital 300 St. Theresa's Hospital 8 Kingston Hospital 9 Other hospitals, institutions and nursing homes 87 842 It will be seen that although a smaller number of births took place in Institutions this year (842 as compared with 855 last year), the percentage is higher (84% as compared with 77%). This of course is because the total number of births this year is lower, and it shows that there is yet no diminuation of the trend towards Institutional births. It should of course not be forgotten that it is not until the housing situation improves that we shall know normal demand on accommodation. 11 TABLE II Showing Births and Deaths with Rates since the Amalgamation of Merton with Morden. Year Estimated population Total Live Births Birth Rate Total Deaths Death Rate Natural Increase 1913 16,767 400 23.5 166 9.9 234 1914 17,500 420 24.0 142 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 14.0 204 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 7.2 346 1937 65,530 812 12.3 487 7.4 325 1938 68,980 990 14.3 509 7.3 481 1939 72,150 1,005 13.9 516 7.2 489 1940 68,540 971 14.2 714 10.4 257 1941 64,920 848 13.06 557 8.58 291 1942 66,590 1,069 16.05 588 8.8 481 1943 65,880 1,146 17.4 575 8.7 571 1944 62,760 1,151 18.3 628 10.0 523 1945 66,050 1.027 15.5 602 9.1 425 1946 73,590 1,261 17.1 568 7.7 693 1947 75,290 1,345 17.86 611 8.1 734 1948 75,220 1,087 14.45 572 7.6 515 1949 75,470 985 13.05 678 8.98 307 DEATHS. The number of registered deaths after adjustment by transferable deaths, is given below: — 678 total deaths of which 358 were males and 320 females. The seasonal mortality is indicated by the deaths for each quarter of the year, which were: — First quarter 205 Second quarter 138 Third quarter 150 Fourth quarter 185 12 Inquests. Inquests were held on 22 deaths occurring in the district, 12 of which were in respect of residents. The verdicts returned were as follows:— (1) Accidental Deaths— Collision with motor vehicles 5 Fall at home 2 Coal gas poisoning 2 Electrocution 1 — 10 (2) Misadventure— Asphyxia from drowning 1 Cardiac failure due to chronic tonsillor sepsis, accelerated by anaesthetic 1 — 2 (3) Suicide by— Asphyxia due to hanging 2 Coal gas poisoning 4 Gunshot wound 1 Pheno-Barbitone poisoning 1 — 8 (4) Murder by— Coal gas poisoning 1 — 1 (5) Open Verdict— Asphyxia from drowning 1 — 1 22 The total number of inquests held were seven more than in the year before. Road accidents were responsible for five of the total accidental deaths, compared with six for the previous year. CAUSES OF DEATH. The expectation of life at birth in England today is 65 years. It has been said that our span of life is predetermined at birth, that it is an hereditary factor. If this were so this expectation would be the real expectation of life. The statistical expectation 13 of 65 years is of course depressed by the number of untimely deaths that occur, the accidents, the infections such as T.B., the malignant growths, these tragedies that cheat so many of their proper entitlement. If preventive medicine were entirely successful, senility would become the only cause of death. Perhaps that is why we lament the infrequency of occurrence of senility in the mortality table, an unjustifiable infrequency we sometimes feel, when we see deaths of old people of 90 years and more attributed to disease. We feel tempted to protest " may nobody be allowed to die of old age !" Table IV on page 17 shows causes of death in 36 groupsThe table this year follows the usual pattern. The four principal diseases responsible for the bulk of the deaths are Heart Disease, Cancer, Intra-cranial Vascular Lesions, and all forms of Tuberculosis, in that order. The number of deaths from Heart Disease was 196 (170); Cancer 152 (110) Intra-cranial Vascular Lesions 70 (66); Tuberculosis 30 (35). Last year's figures are shown in parenthesis. In comparing this year's figures with those for previous years it should be borne in mind that this year's total number of deaths has increased by 106 and therefore it is to be expected that the figures for the diseases contributing most to the total will themselves show an appreciable rise. Nevertheless, as reference to page 16 will confirm, the number of deaths from Cancer is raised sufficient to be reflected in the Cancer rate, and at 2 per thousand population it is the highest rate ever to be recorded for the area. The deaths from Tuberculosis show a welcome drop from 35 to 30, and this question is dealt with in greater detail later in the report. Table IV is a statistical analysis of the deaths in the area prepared according to the rules of classification to achieve statistical uniformity. Two additional tables have been prepared this year showing the deaths in age groups and giving the secondary causes of death as mentioned on the certificate, so as to enable us to form some idea as, to the frequency of occurrence of some of the commoner and some of the rarer diseases which are not included in the groups in Table IV because they have not been recorded as the cause of death. These tables on pages 18 and 19 reveal some very interesting facts. It will be seen that up to the age of 56 the number of male deaths is double that of the female deaths and that the male 14 deaths are in excess of the female deaths for all age groups up to the 76-85 group, after which there are a greater number of female deaths than male. It will be seen that the highest number of deaths occurs in the 66-75 group (177), and that the next highest, with 160, is the 76-85 group. These groups provide more than half the total number of deaths. It is of interest perhaps that out of 162 deaths from Heart Disease, Rheumatism and specific infections have only been mentioned 23 times. Either Rheumatism is an exaggerated cause of Heart Disease, or Heart Disease is exaggerated as a cause of death. Coronary Thrombosis, however, is recorded 70 times as a contributory cause. It is worth noting, too, that out of 387 old persons of over 65, in only 52 of them is old age mentioned as a contributory factor, and in only 8 of them is old age recorded as the cause of death. Out of 46 deaths in old people over 86, old age is only responsible for 2 deaths, and of the 19 who were 90 and over it was only recorded as the primary cause of death in 3 cases. Enlargement by growth of the prostate, including Cancer of the prostate of which there were 2 cases, is recorded as having played a part in 17 deaths, the greatest number -7- falling in the age group 66-75. There were 5 in the 56-65 group, and none under the age of 56. Asthma, though by impression a relatively common disease, is rarely recorded on the certificates as a contributory cause of death (it was mentioned in only 7 cases), and Diabetes was recorded 10 times only. On pages 20 and 21 will be found graphs showing reports of the number of deaths from violence, suicide, and from road accidents for the past 30 years. The road deaths are compiled from the Inquests and include deaths of non-residents. They are in fact deaths occurring in the streets and roads of Merton and Morden. The peak of road deaths occurred in 1933 (20), and 1934 was a bad year with only one less. However, taking into consideration the population of the district, 1929 (14 deaths) would appear to be our worst year with a death rate of 0.51 per 1,000 population, as the lower graph on page 20 shows. 1946 was also a bad year (12 deaths) but when the number of vehicles on the road is taken into consideration (see top of graph on page 20) there seems no doubt that the local death rate from road accidents has greatly improved. The graph on page 21 giving the deaths from violence, (apart from suicide) shows a peak in 1934 and minor peaks in 1933 and 1938, with the exception of the war years, especially 1940 and 1944, when a considerable number of deaths were due to enemy action. 15 CANCER DEATH RATE. No. of deaths from Cancer for past 10 years. 1940 76 1945 116 1941 85 1946 126 1942 103 1947 118 1943 116 1948 110 1944 107 1949 152 Year. Death Rate per 1,000 population. Year. Death Rate per 1,000 population. 1940 1.2 1945 1.7 1941 1.3 1946 1.7 1942 1.5 1947 1.5 1943 1.7 1948 1.5 1944 1.7 1949 2.0 TABLE III. Deaths from Respiratory Diseases, 1929-1949. Year Bronchitis Pneumonia Other Respiratory Diseases Total Death Rate 1929 11 20 4 35 1.2 1930 2 10 3 15 0.4 1931 8 24 4 36 0.8 1932 11 27 3 41 0.8 1933 12 32 6 50 0.9 1934 7 38 4 49 0.8 1935 9 22 6 37 0.6 1936 2 35 2 39 0.6 1937 14 31 6 51 0.8 1938 15 27 7 49 0.7 1939 5 20 9 34 0.4 1940 38 40 15 93 1.3 1941 30 30 6 66 0.9 1942 9 12 20 41 0.62 1943 25 36 9 70 1.05 1944 26 29 7 62 0.98 1945 36 22 12 70 1.05 1946 22 17 17 56 0.76 1947 31 25 4 60 0.79 1948 30 15 9 54 0.72 1949 29 24 6 59 0.78 16 TABLE IV. Causes of Death during the year 1949. No. Cause of Death Males Females Total 1 Typhoid and Paratyphoid Fevers — 1 1 2 Cerebro spinal fever — — — 3 Scarlet Fever — — — 4 Whooping Cough — — — 5 Diphtheria — — — 6 Tuberculosis Respir. System 16 8 24 7 Other forms of Tuberculosis 3 3 6 8 Syphilitic disease 4 2 6 9 Influenza 5 5 10 10 Measles — — — 11 Ac. PolioMyel. and polioencephalitis 1 — 1 12 Ac. inf. encephalitis — — — 13 Cancer of buc. cav. and oesoph. (M) uterus (F) 3 8 11 14 Cancer of stomach and duodenum 18 8 26 15 Cancer of breast — 21 21 16 Cancer of all other sites 50 44 94 17 Diabetes — 2 2 18 Intra-cranial vascular lesions 25 45 70 19 Heart disease 108 88 196 20 Other dis. of circ. system 13 12 25 21 Bronchitis 19 10 29 22 Pneumonia 13 11 24 23 Other respiratory diseases 5 1 6 24 Ulcer of stom. or duodenum 7 — 7 25 Diarrhoea under 2 years — — — 26 Appendicitis 2 — 2 27 Other digestive diseases 9 9 18 28 Nephritis 6 6 12 29 Puer. and post abort, sepsis — — — 30 Other maternal causes — — — 31 Premature birth — 7 7 32 Con. mal. birth inj. inf. dis. 11 4 15 33 Suicide 4 3 7 34 Road traffic accident 3 1 4 35 Other violent causes 6 7 13 36 All other causes 27 24 41 Total all causes 358 320 678 17 TABLE V. Primary Causes of Death. Cause of Death AGE GROUPS Total 1-5 6-15 16-25 26-35 36-45 46-55 56-65 66-75 76-85 86-95 Over 95 1. Typhoid and Paratyphoid Fevers — — — — — — 1 — — — — 1 6. Tuberculosis of Resp. System — — — 8 4 3 8 3 2 — — 28 7. Other forms of Tuberculosis 1 — — 2 — — 1 — — — — 4 8. Syphilitic disease 3 3 3 — — 9 9. Influenza — — 1 — 1 — 1 1 5 2 1 12 11. Ac. Polimyelitis and Polioencephalitis — — — — — — — — — — — 1 13. Cancer of buc. cavity and oesoph (M.), uterus (F.) — — — — — 1 — 2 2 — — 5 14. Cancer of stomach and duodenum — — — 1 1 5 7 9 1 1 25 15. Cancer of breast — — — — 6 5 7 4 1 — 23 16a. Cancer of uterus and appendages — — — — — 6 4 1 1 — — 12 16. Cancer of other sites — — — 2 6 13 23 23 16 2 1 86 17. Diabetes — 1 — — — — — 3 1 — — 5 18. Intra-cranal vascular lesions — — — 1 3 4 14 26 30 6 1 85 19. Heart disease — — — — 4 17 27 52 50 12 — 162 20. Other diseases of circ system — — — — — 1 1 11 6 — — 19 21. Bronchitis — — — — — 1 5 6 5 4 — 21 22. Pneumonia — — — — — 1 2 2 1 — — 6 23. Other respiratory diseases — 1 — — 2 3 4 2 5 1 — 18 24. Ulcer of stomach or duodenum — — — 1 — 1 5 1 — — — 8 26. Appendicitis — — 1 — — — — 1 — — — 2 27. Other digestive diseases 2 — — — 1 1 4 4 — 1 — 13 28. Nephritis — — 1 1 1 — — 3 3 — — 9 33. Suicide — — — 1 3 — 3 — — — — 7 34. Road traffic accident — 1 1 — 1 — 1 — — — — 4 35. Other violent causes — 2 1 1 — — 3 3 2 2 — 14 36. All other causes 1 1 2 1 1 4 10 14 23 13 2 72 Total 4 6 7 20 28 67 132 177 160 45 5 651 Totals by sexes M. 3 M. 2 M. 6 M. 11 M. 18 M. 41 M. 86 M. 92 M. 66 M. 19 M. 1 M. 345 F. 1 F. 4 F. 1 F. 9 F. 10 F. 26 F. 46 F. 85 F. 94 F. 26 F. 4 F. 306 TABLE VI. Secondary Causes of Death. (Primary where not included in Table V.) Cause of Death AGE GROUPS Total 1-5 6-15 16-25 26-35 36-45 46-55 56-65 66-75 76-85 86-95 Over 95 Rheumatic or Specific Infection of Heart – – – – 3 6 7 4 2 1 – 23 Diabetes – 1 – – – – – 7 2 – – 10 Leukaemia 1 – 1 – 1 2 – 1 – – – 6 Prostate growth – – – – – – 5 7 4 1 – 17 Parkinson's Disease – – – – – – 1 3 1 – – 5 Asthma – 1 – – – – 1 2 3 – – 7 Intussusception 1 – – – – – – – – – – 1 Dysentery 1 – – – – – – – – – – 1 Meningitis – – 1 – – – – – – – – 1 Muscular Dystrophies – – – – – – – – – – – 1 Tumours of Central Nervous System – – – 1 2 – 2 – – – – 1 Coronary Thrombosis – – – 1 – 11 13 26 18 2 – 5 Gastric Ulcer – – – – – – 6 – – – – 70 Hemiplegia and Paraplegia – – – – – – 2 1 5 1 – 6 Disseminated Sclerosis – – – – – – 1 – – – – 9 Ac. Intestinal Obstruction – – – – – – 2 – 2 – – 1 Senility — — — — — — – 7 29 14 2 4 52 Total 3 2 2 2 6 19 40 58 66 19 2 219 Total Deaths in Group 4 6 7 20 28 67 132 177 160 45 5 651 19 20 21 MATERNAL MORTALITY. The maternal mortality rate for the year 1949 is Nil. It has been pointed out before that dealing with small figures such as those provided by our population, a single death is reflected in the mortality rate by more than 1 per thousand. For this reason we have published the rates for the past 20 years. These figures will be found in the table below. It will be seen that we have had a Nil mortality 3 times in the past ten years and that only 3 times in that period has it been above 1. In the 20 years ended this year there have been 40 maternal deaths and 18,977 births. This expressed as a rate gives an overall rate for the period of 2.11. TABLE VII. Maternal Mortality, 1930-1949. With Comparable Rates for England and Wales. Year Death rate per thousand total births. Sepsis Other causes Total Merton and Morden England and Wales Merton and Morden England and Wales Merton and Morden England and Wales 1930 — 1.54 2.2 2.06 2.2 3.60 1931 1.6 1.41 3.1 2.02 4.7 3.43 1932 5.1 1.33 2.5 2.12 7.6 3.46 1933 2.9 1.49 1.4 2.23 4.3 3.72 1934 2.5 1.59 2.5 2.21 5.0 3.80 1935 — 1.34 2.6 2.06 2.6 3.41 1936 2.4 1.18 — 2.01 2.4 3.19 1937 1.2 0.79 1.2 2.01 2.4 2.79 1938 0.98 0.70 1.96 1.99 2.94 2.70 1939 — 0.63 3.93 1.94 3.93 2.57 1940 1.04 0.55 — 1.69 1.04 2.24 1941 — 0.48 2.3 1.78 2.3 2.26 1942 0.93 0.42 1.87 1.60 2.80 2.02 1943 0.85 0.39 — 1.45 0.85 1.84 1944 — 0.28 0.84 1.24 0.84 1.52 1945 — 0.24 0.97 1.23 0.97 1.47 1946 — 0.31 — 1.12 — 1.43 1947 0.73 0.26 — 0.92 0.73 1.18 1948 — 0.24 — 0.78 — 1.02 1949 — 0.22 — 0.76 — 0.98 22 INFANT MORTALITY. The analysis of the infant deaths below and on the next page shows once more that it is the neo-natal deaths, i.e. deaths occurring in the first month of life, that contribute largely to this mortality. It will be seen that of the 24 deaths in infants, 22 were neo-natal deaths and the two who survived one month were only 2 months old at death; and in one of these death is due to a failure in development. Careful study of these deaths shows that all of them (except possibly one of the 2 months old infants) are due either to failures in development or are a result of the hazards of reproduction. It will be seen that in 9 of them Prematurity is given as the cause; this represents 37.5 % of the total infant mortality. In 4 others intra-cranial injury (damage caused by the mechanics of birth) is the direct cause of death. These two causes bring the percentage up to 54%. With 5 deaths due to congenital deformities or developmental failures 18 of the 24 deaths (or 75%) are accounted for. This is 18 of the 22 neo-natal deaths or 82% of them. These 22 neo-natal deaths, together with 14 stillbirths, represent an annual reproductive loss of 46 per 1,000 births. A Table is reproduced on page 24 showing the trend of infant mortality and stillbirth rate for the past 10 years. The stillbirth rate shows a gratifying decline; we can only hope that a fall in the neo-natal deaths will enable the infant mortality graph to follow suit. Infant Deaths — With causes of death. Sex. Age. Cause of Death. Male 8 hours Atelectasis. Prematurity (28 weeks gestation). Male 4 days Peritonitis. Female 10 hours Prematurity (28 weeks gestation). Female 2 days Cerebral Haemorrhage. Torn Tentorium Cerebelli. Prematurity (33 weeks gestation). Atelectasis. Male 2 days Congenital Heart Disease. (Patent Foramen Ovale). Male 3 days Multiple Congenital Deformities of Alimentary and Renal Systems. Female 2 days Tentorial Tear and Atelectasis. 23 Sex. Age. Cause of Death. Male 3 hours Cerebral Haemorrhage. Torn Tentorium Cerebelli. Female 2 months Acute Bronchiolitis. Female 4 hours Extreme Prematurity (weight 1 lb. 12 ozs). Female 1 hour Prematurity. Male 2 months Broncho Pneumonia. Congenital Heart Disease (Patent Ductus). Male 20 minutes Asphyxia Neonatorum. Female 30 minutes Prematurity. Caesarian Section. Pre Eclampsia. Male 1 hour Prematurity. Atelectasis. Male 6 hours Atelectasis. Female 6 days Meningocele. Male 2 days Cerebral Haemorrhage. Tentorial Tear. Congenital Abnormality and Birth Trauma. Multiple Congenital Abnormalities. Male 1 day Pulmonary Atelectasis. Female 1 day Prematurity. Female 2 days Prematurity. Male 2 days Pneumonia. Congenital Morbus Cordis. Hare Lip and Cleft-Palate Female 2 days Prematurity. Male 2 days Haemolytic Disease of Newborn. TABLE VIII. Infant Mortality and Stillbirth Rates for the past 10 years. Year Infant Mortality Rate Stillbirth Rate 1940 34.3 29 1941 42.2 34.2 1942 33.9 24 1943 23.5 23.5 1944 28.7 22.09 1945 33.1 24.6 1946 22.2 23.9 1947 30.4 21.1 1948 24.8 18.9 1949 24.3 14.01 24 PREMATURE BABIES. There were 54 premature births notified during the year. This is a considerable increase over previous years. Last year there were 37 and the previous year 38. 13 of these babies failed to survive one month. Of those whose weights are known 2 were under 2 lbs. weight at birth and a further 3 were under 3 lbs. Only 2 of them were over 5 lbs. at birth. Of the 41 who did survive one month 1 was 3 lbs. and a further 8 were under 4 lbs. The total number of premature babies notified during the year were as follows, born:— (a) At home 7 (b) In hospital 47 The number of those born at home:— (a) Who were nursed entirely at home 5 (b) Who died during the first 24 hours — (c) Who survived at the end of one month 5 The number of those born in hospital:— (a) Who died during the first 24 hours 7 (b) Who survived at the end of one month 36 25 SECTION B. — HEALTH SERVICES. Nursing in the Home. There are three Associations carrying on this work in the area, all affiliated to the County Nursing Association, the County Council now being responsible for this service. Details of the work carried out by these Associations during 1949 are as follows:— (1) The Merton District Nursing Association employs one nurse for general nursing, no midwifery or maternity nursing being und.ertaken. The district this Association serves is approximately the ecclesiastical parish of St. Mary's. A total of 452 cases involving 2,456 visits were attended during the year and of these 11 cases were children under 5 years of age, to whom 71 visits were made. (2) The St. Helier District Nursing Association employs one full-time and two part-time nurses 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 230 cases were dealt with by the St. Helier District Nursing Association, 24 of these being children under 5 years of age. The total number of visits made was 4,281, of which 110 were in respect of children under 5 years. (3) The Wimbledon District Nursing Association serves Wimbledon and the western part of this district. Two full-time nurses and two part-time nurses are employed for general nursing in Merton and Morden. The figures relating to cases and visits in this district during tne year are as follows:— Cases Visits Children under 5 years 23 123 Other cases 418 4,827 441 4,950 Hospital Car Service. This most valuable service was continued during the year, relieving the ambulances of a great burden of calls by providing transport for out-patients requiring hospital treatment. The service, under the auspices of the British Red Cross and St. John Ambulance Brigade, is conducted on a voluntary basis by public-spirited persons who put themselves and their vehicles at the disposal of the organisation. A charge of 6d. per mile is made to cover partly the actual running cost. 26 Tuberculosis Dispensaries. The provision of treatment and investigation of Tuberculosis is undertaken by the Regional Hospital Board. The County Council are responsible for the preventive side of the work, the Health Visitors and Almoners working in the Chest Clinic at the St. Helier Hospital being employed by the County Council. Three-elevenths of the Tuberculosis Officer's time is allocated to the preventive side of the work and is also the responsibility of the County Council. The sessions held at the Chest Clinic for Merton and Morden patients are as follows:— Mondays at 2.0 p.m. Wednesdays at 9.30 a.m. Fridays at 2 p.m. 1st Monday in the month at 5 p.m. (old cases only). Venereal Diseases. The treatment both in-patient and out-patient, of venereal disease is the responsiblity of the Hospital Board and for our area this treatment is mainly carried out at the St. Helier Hospital, although both Kingston and Croydon General Hospitals are near enough to serve the area as well. The preventive side of the work, domiciliary visiting of contacts, etc., remains the responsibility of the local health authority and the County Council have appointed two health visitors especially for this purpose. Clinics are held at these hospitals as follows: — St. Helier Hospital, Wrythe Lane, Carshalton Males — Mondays 5-7 p.m. Females— Wednesdays 4.30-7 p.m. Fridays 1.30-3 p.m. Croydon General Hospital Males — Tuesdays at 7 p.m. Saturdays at 10.45 a.m. Females — Wednesdays at 2.30 p.m. Thursdays at 11 a.m. Fridays at 5.30 p.m. Kingston Hospital, Wolverton Avenue, Kingston-on-Thames Females— Thursdays 5-7 p.m. 27 HOSPITALS. Smallpox. The arrangements whereby cases of Smallpox were admitted to the Surrey County Isolation Hospital, Clandon, have now been discontinued. The South Bast Metropolitan Regional Hospital Board have a agreed that any cases should be admitted to the Joyce Green Hospital, Dartford, Kent. No cases occurred in this district during the year. Infectious Disease. The Wandle Valley Hospital under the Regional Hospital Board, serves this area together with three other neighbouring areas, Mitcham, Beddington and Wallington and Coulsdon and Purley. The hospital has accommodation for 80 patients. During the year 135 patients from our district have been treated in the hospital. Table IX shows in detail the conditions for which admission was necessitated. TABLE IX. Cases admitted to the Wandle Valley Isolation Hospital during the Year 1949. Disease Cases Deaths Scarlet Fever 113 – Measles 2 – Erysipelas 4 – Whooping Cough 2 – Puerperal Fever 1 – Tonsillitis 4 – Diphtheria 1 – Poliomyelitis and Polioencephalitis 6 1 Influenza 1 – Bronchitis 1 – Total 135 1 General and Maternity. 1. The Nelson Hospital. The accommodation of this hospital, which serves the Wimbledon, Merton and Morden area is 106 beds, 47 of which are maternity beds. 2. Other Hospitals. Other hospitals available for the use of residents of the district include the St. Helier Hospital situate just beyond the boundary of our district in the Carshalton area and the Epsom and Kingston Hospitals which are within a matter of five miles or so. 28 MENTAL DISEASE. Cases dealt with under the Lunacy Acts, 1890, in the district of Merton and Morden. There were 26 cases certified under these Acts during the year. Below is given the provisional classification according to the condition on admission. Male Female Total Senile Dementia 1 7 8 Delusional Insanity 3 5 8 Suicidal 3 3 6 Epilepsy 1 — 1 Mental Deficiency 1 — 1 Schizophrenia 1 — 1 Hallucinated and Depressed 1 — 1 Under Sec. 1, Mental Treatment Act, 1930 11 15 26 22 30 52 Of these cases 16 were certified under Section 16, 6 were placed under observation under Section 20, and 4 were removed to hospital under an Urgency Order under Section 11. In addition 67 patients (22 male and 45 female) were admitted direct to Mental Hospital under Section 1 of the Mental Treatment Act, 1930, as voluntary patients. NATIONAL ASSISTANCE ACT, 1948. Two cases came under consideration with regard to the necessity of operating Section 47 of the National Assistance Act to secure their compulsory removal to an Institution. The first case was an old lady living alone, who could not be persuaded to enter a Home voluntarily. Representations had been made over a considerable period by a relative that she ought to be removed. Eventually, towards the end of 1949 the situation had deteriorated to such an extent that it appeared that removal in her own interest was essential. Accordingly the Council was recommended to take the necessary action and a resolution was passed to take the necessary legal steps. It so happened, however, that while this was going on the old lady had an accident at home and was taken to hospital. It was then decided to take steps to secure that she did not return to 29 the same conditions. This action was rendered unnecessary, however, as she failed to recover from her accident. The second case was of an old lady who was suffering from Senile Dementia, and as action under the Lunacy Acts seemed more appropriate, steps were taken to secure her certification and she was admitted to a Mental Hospital. During the year there were no cases compulsorily removed, but Court proceedings were initiated in the one case mentioned above. SECTION C. — SANITARY CIRCUMSTANCES. Clean Food Campaign. With the strengthening of the sanitary staff by an additional appointment and the securing of highly experienced staff it has been possible to embark on a vigorous campaign for improvement in food distribution and manufacture. The question of establishing Guilds, with standards or socalled Codes of Practice, was given careful consideration by the Council but in view of the fact that new Model Byelaws were to be made available in due course by the Ministry of Food which would contain practically all the features of the various Codes of Practice with the additional force of the law behind them, and the obvious difficulties in administering such an organisation, the Committee decided to devote their efforts towards educational methods of approach. As a first step it was decided to set up a Food Advisory Committee with representatives of all the food traders in the area. It was hoped to secure their support in staging a Clean Food Exhibition, which was regarded as an ideal way of opening such a campaign. These activities extend beyond the period covered by this report and the success of the Food Exhibition will be a matter for record on a future occasion. Food and Drugs Act. The sampling of ice cream for purity control, as will be seen on page 38 occupies a considerable proportion of the time spent on Food and Drug supervision. The greater availability of fats has been shown by the analyses done during the year to have resulted in a very great improvement in the quality of ice-cream. This is of interest when we remember that the setting up of a minimum standard of fat content was under consideration a short time ago. It seems that trade competition has been sufficient to stimulate the production of a good product. 30 On the 1st May, 1949 the special defence that they had ordered but had been unable to obtain the necessary apparatus, in any proceedings for failure to instal suitable cooling apparatus, was withdrawn. The special defence was introduced in the Ice Cream (Heat Treatment etc.) Regulations, 1947, because at that time there was a serious shortage of cooling apparatus. It was later extended until the 1st May, 1949, by the Ice Cream (Heat Treatment etc.) Amendment Regulations 1948. Public Cleansing. The Council took over the collection of house refuse themselves in October, 1909. It had been previously done under contract. From that time a weekly collection has been maintained with the exception of occasional periods during the War when shortage of labour caused disorganisation. It may be of interest to observe that 36 years ago in his report the Sanitary Inspector recommended a bi-weekly collection of refuse, and it is perhaps of further interest to note that the 3,900 tons of refuse collected that year consisted of " house and garden " refuse. The removal of garden refuse is a service which would do much to improve the amenities for the residents by obviating the need for burning garden waste on Sunday afternoons or summer evenings. During the year 15,313 tons of house refuse was collected and disposed of. The salvage tonnage for the year was as follows :— Tons. Tons. Paper 454 Bottles and Glass 147 Metal 568 Rags 54 Pig Foods 954 Drainage and Sewerage. No improvement schemes for soil sewerage have been considered necessary. Rivers and Streams. During the year the Pickle Ditch along Phipps Bridge Road has been culverted and the normal cleaning and maintenance of waterways has been carried out by the Surrey County Council. Contraceptives in Slot Machines. The sale of contraceptives from slot machines outside shop premises necessitated the making of a special byelaw. In common with other districts the practice was instituted in this district and the Council adopted the byelaw prohibiting the sale by this method. 31 REPORT OF THE CHIEF SANITARY INSPECTOR. Mr. Chairman, Ladies and Gentlemen, I have pleasure in presenting the Annual Report which summarises the work carried out by your Sanitary Inspectors during the year ended 31st December, 1949. Housing Inspections. The total number of houses inspected for "sanitary defects" under the Public Health and Housing Acts was 761. Action taken in connection with defective dwelling-houses is set out in the housing table on pages 42 and 43. Summary of Nuisances Abated and Sanitary Improvements Effected. Ceilings cleansed or repaired 193 Coppers provided or repaired — Dampness in premises remedied 90 Drains exposed and repaired 23 Drains reconstructed 1 Defective sashcords renewed 27 Dustbins provided 48 Floors repaired 70 Fresh air inlet valves provided and repaired 5 Inspection chamber covers provided 4 Obstructions removed from drains 21 Rain water pipes renewed or repaired 14 Rooms cleansed 28 Roofs repaired 80 Gutters repaired 34 Sink wastes repaired 18 Walls repaired 253 W.C. cisterns provided — W.C. cisterns repaired 19 Water Closets cleansed 2 W.C. pans provided 26 Windows repaired or renewed 82 Fireplaces and stoves renewed or repaired 46 Sinks provided 3 Offensive accumulations removed 9 Water supply for domestic use 23 Verminous premises fumigated and cleansed 1 Ventilation provided under floors 15 Sanitary accommodation for workshops 2 Miscellaneous 168 Notices Served. Intimation notices 400 Statutory notices:— Public Health Act, 1936 45 Housing Act, 1936 — 32 Legal Proceedings. Legal proceedings were instituted during the year with the results stated :— 1. Failure to comply with statutory notices—Section 93, Public Health Act, 1936, in respect of two properties:— Orders of Court to abate nuisances within 56 days. 2. Failure to comply with statutory notices—Section 93, Public Health Act, 1936, in respect of six properties:— Orders of Court to abate nuisances within 28 days. Owner fined 40/- and costs in each case. Drainage Work. At 15 houses the drainage systems were entirely reconstructed and at 38 houses extensive repairs to drains were carried out. Smoke and water tests were applied to the drains of houses in 107 instances, and obstructions were removed from drains at 61 houses. Food Supply. The total number of inspections made to premises where articles of food are prepared or exposed for sale was 1,369. Towards the end of the year a systematic survey of all food shops and catering establishments was commenced with a view to raising the standard of cleanliness under which foods are prepared, stored and distributed. At a number of premises, improvements in sanitary conditions were effected. Unsound Food. The undermentioned articles of food were found, upon inspection, to be unfit for human consumption; were surrendered and either destroyed or disposed of for animal feeding or salvage:'— Description. Amount. Cause. Beef 986 lbs. Putrefaction and decomposition Mutton 457 lbs. Putrefaction and decomposition Pork 313 lbs. Decomposition Tripe 115 lbs. Decomposition Veal 7 lbs. Decomposition Fish 248 stone Decomposition Wheat Flakes 6 pkts. Infested with Weevil Miscellaneous Essences 22 pkts. Deterioration Pickles 31 jars Unsound Spice 18 lbs. Unsound Christmas Pudding 1 lb. Unsound Dried Egg 1 pkt. Mouldy Rabbits 1026 lbs. Decomposition Chocolate Crunch 6 lbs. Maggoty Flour 75 lbs. Invested with Weevil 33 Description. Amount. Cause. Prawns 154 lbs. Decomposition Salad Cream 15 jars Unsound Chocolate Spread 56 jars Mouldy Brawn 10 lbs. Decomposition Chocolate Fudge 48 lbs. Contamination Bacon 26 lbs. Decomposition Chickens 82 lbs. Decomposition Cheese 23 lbs. Decomposition Cake 9½ slabs Mouldy Oatmeal 18 lbs. Decomposition Eggs 247 Decomposition Meat Galantine 230 lbs. Decomposition Rolled Oats 176 lbs. Moth larvae infestation Creamola Pudding 11 pkts. Invested with Weevil Semolina 36 lbs. Contamination Sultanas 30 lbs. Soured Dates 145 lbs. Soured and mite infested Cut Peel 70 lbs. Unsound Pastry Mix 171 pkts. Soapy smell and taste Tinned Meat, Milk, Fish, Vegetables, Fruit, etc. 3193 tins Blown, punctured, leaking, mouldy, sour and unsound 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 — — — — 191 Number inspected — — — — 191 Number found fit for human consumption — — — — 191 Organs condemned. Reason for condemnation. 1 head Tuberculosis 34 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. One hundred and five inspections were made to dairies and milk shops during 1949. Forty nine samples of milk were submitted for bacteriological examination during the year. Three samples of Tuberculin Tested, four of Pasteurised and three of Tuberculin Tested (Pasteurised) Milk failed to conform to the prescribed standard. Results of Chemical Analyses of New Milk Samples. Solids not fat (legal standard is 8.5%). Less than 8.5 8.5 8.6 8.7 8.8 8.9 9.0 9.1 9.2 Total 1 — 7 10 5 4 — – — 27 Milk fat (legal standard 3.0%). Less than 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 — 1 1 4 4 4 7 2 3 — — — 27 The undermentioned licences were granted to dealers under the Milk (Special Designations) Regulations and were in force at 31st December, 1949 :— Dealers Licences. Pasteurised 13 Tuberculin Tested 10 Sterilised 13 Supplementary Licences. Pasteurised 17 Tuberculin Tested 16 Sterilised 17 35 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 Almond Oil 1 1 — — Aspirin Tablets 1 1 — — Baking Powder 1 1 — — Bicarbonate of Soda 1 1 — — Black Pudding 2 — — Boracic Ointment 1 1 — — Brawn 1 1 — — Brown Bread 1 1 — — Bun Flour 1 1 — — Butter 1 1 — — Camphorated Oil 1 1 — — Chocolate Cup 1 1 — — Cocoa 1 1 — — Coffee and Chicory Essence 1 1 — — Condensed Milk 1 1 — — Cough Mixture 1 1 — — Curry Powder 2 — — Epsom Salts 1 1 — — Essence of Rennett 1 1 — — Eucalyptus Oil 1 1 — — Faggots 1 1 — — Flour Mixtures 2 — — Fish Paste 8 — — Flavourings 3 3 — — Friars Balsam 1 1 — — Fruit Malt Syrup 1 1 — — Fruit Sauce 1 1 — — Gelatine 3 1 2 Stocks withdrawn from sale Gravy Powder 1 1 — — Ground Coffee 2 — — Ground Ginger 1 1 — — Ground Nutmeg 4 4 — — Ground White Pepper 1 1 — — Haslet 1 1 — — Iodised Throat Tablets t 1 — — Jam 2 2 — — Kruschen Salts 1 — 1 Manufacturer s explanation accepted Liquid Paraffin 2 2 — — Liver Sausage 2 2 — — Margarine 1 1 — — Marmalade 1 1 — — Meat Paste 1 1 — — Meat Soup 2 — — Manufacturer's explanation accepted Milk 30 29 1 Formal samples taken and found to be genuine 36 Article Total Samples Genuine Not Genuine Action Taken Mixed Spice 1 1 — — Mustard 1 1 — — Palm Kernel Oil 1 1 — — Pastry Mix 1 — 1 Remaining stock surrendered and destroyed Pickles 2 2 — — Saccharine Tablets 3 3 — — Sage 1 1 — — Salad Cream 1 1 — — Sausage Meat 5 4 1 Formal sample of sausage taken (see below) Sausages 10 9 1 Court proceedings. Fines £21 and £6 6s. 0d. costs awarded Savoury Spread 2 2 — — Self-raising Flour 2 2 — — Seidlitz Powder 1 1 — — Shredded Suet 1 1 — — Sponge Mixture 2 2 — — Steak and Kidney Pudding 1 1 — Sulphur Ointment 1 1 — — Sulphur Tablets 1 1 — — Table Jelly 1 1 — — Tincture of Iodine 1 1 — — Tomato Ketchup 2 2 — — Vegetable Soup 1 1 — — Zinc Ointment 1 1 — — Total 138 129 9 — 37 Ice-cream (Heat Treatment) Regulations, 1947. These regulations came into operation on the 1st May, 1947. At the end of the year, there was only one manufacturer of ice-cream on the register and 69 dealers and 15 vendors were registered. 49 samples were obtained and submitted for examination with the following results:— No. Grade Methylene Blue Test Coliform B. Remarks 1 1 Satisfactory Absent 2 1 „ „ 3 1 „ „ 4 1 „ „ 5 1 „ „ 6 2 „ Present 7 3 Unsatisfactory „ 8 1 Satisfactory „ 9 2 „ „ 10 3 Unsatisfactory Absent 11 1 Satisfactory „ 12 3 Unsatisfactory Present 13 4 „ „ 14 4 „ „ 15 4 „ „ 16 3 „ Absent 17 4 „ „ 18 4 „ Present 19 3 „ „ 20 3 „ „ 21 1 Satisfactory „ 22 3 Unsatisfactory „ Faecal coli present 23 3 „ Absent 24 3 „ Present 25 1 Satisfactory Absent 26 3 Unsatisfactory Present Faecal coli present 27 2 Satisfactory „ Faecal coli present 28 3 Unsatisfactory „ 29 2 Satisfactory Absent 30 2 „ „ 31 1 „ Present 32 3 Unsatisfactory „ Faecal coli present 33 1 Satisfactory Absent 34 3 Unsatisfactory Present Faecal coli present 35 3 „ „ 36 3 „ Absent 37 2 Satisfactory Present 38 3 Unsatisfactory „ Faecal coli present 39 2 Satisfactory „ Faecal coli present 40 3 Unsatisfactory „ 41 1 Satisfactory Absent 42 1 „ Present 43 2 „ 44 2 „ Absent 45 1 „ „ 46 1 „ „ 47 1 „ „ 48 1 „ „ 49 1 „ „ 38 Factories and Workplaces. The number of inspections made to premises registered under the Factories Act, 1937 was 246. Defects relating to sanitary conveniences, ventilation and other sanitary matters were dealt with at 31 premises. The table on page 44 gives details of action taken during the year. Water Supply. The district is supplied by the Metropolitan Water Board and by the Sutton District Water Company. Their respective distributive areas being 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 investigation. The Board supplies copies of their official minutes in which the results of the 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 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. There are three deep wells in the district, the supplies from which are used mainly for industrial purposes. They are drawn from beneath the London clay. The boreholes vary between 400 ft. and 500 ft. in depth and their capacity between 3,300 galls, and 7,000 galls, per hour. Seven samples of water from domestic taps were submitted for chemical or bacteriological examination. The reports on each sample were satisfactory. Water Courses. Fifty-eight inspections were made of the water courses in the district, particularly of the River Wandle, and Beverley and Pyl Brooks for the purpose of detecting pollutions and samples were obtained and sent for chemical analysis. Four instances of pollution were discovered during the year and appropriate action was taken. Mosquitoes. A number of complaints were received from residents and spraying of water courses, ditches and stagnant ponds was carried out particularly in the vicinity of the Council's recreation grounds and open spaces during the breeding season. 39 Rats and Mice (Destruction) Act, 1919 — 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 Rodent Operator is employed and a free service is provided for householders but a charge is made according to an agreed scale when work is undertaken at business premises. During the year 868 visits were made to premises where infestations were known or suspected and at 138 premises the infestations were cleared. Routine poisoning of the Council's sewers in the older parts of the district was carried out and an average number of 70 manholes were dealt with during each day of the treatment Periodic treatment of the Council's refuse tip at Garth Road was also carried out during the year. Smoke Abatement. A number of complaints were received relating to excessive smoke emitting from certain factory chimneys. 17 observations were made and in 4 instances, the nuisances were satisfactorily abated. Inspections of Cinemas and other Licensed Premises. Periodical inspection of the two cinemas in the district and other licensed premises was made during the year. All the sanitary conveniences at these premises were inspected and found to be generally well maintained. Shops Acts, 1912—1936. The following statement summaries the inspections made, the infringements discovered and other matters dealt with during the year. No. of Inspections:—Day Visits 703 Evening Visits — Infringements: — 1. Evening closing hours 2. Half-day closing 2 3. Hours of employment for young persons — 4. Seats not provided for females 1 5. Prescribed notices not correct or exhibited 115 6. Sanitary arrangements unsatisfactory 2 7. Reasonable temperature not maintained — 40 Summary of Sanitary Inspections. Housing—primary visits 911 Re-inspections—work in progress 2,025 Re overcrowding provisions 268 Miscellaneous, housing 408 Drainage work 959 Factories and Workplaces 386 Stables and Piggeries 49 Rats and Mice destruction 868 Enquiries-—infectious diseases 441 Smoke abatement 34 Food shops, etc 1,369 Milk supply 105 Rivers and Streams—pollution 58 Miscellaneous 2,086 I would like to take this opportunity of expressing my appreciation and thanks to the Chairman and Members of the Public Health Committee for their support during the year. I am, Ladies and Gentlemen, Your obedient Servant, F. C. THOMAS, Chief Sanitary Inspector. August, 1950. 41 SECTION D. — HOUSING. Housing and Overcrowding. Since the end of the war the Council has built 464 houses and flats, in fact has acquired every available bit of land in order to overcome this most serious source of discontent and cause of misery and family unhappiness. This shortage of houses remains the biggest single adverse factor in the well-being of the community and its evil influence permeates every aspect of the community life. It is a strain on the relations of parents and children, it is a cause of difficulty in marriage, and it deterrent effect must often cause postponement of marriage with its anti-social consequences. During the year 49 new houses and flats were built and 24 were reconditioned and made habitable. The number of applicants on the waiting list at the end of the year was 2,979. Arising out of rehousing enquiries, 87 complaints of overcrowding were received. Of these, 21 were found to be overcrowded within the standards laid down by the Housing Act, 1936. The housing situation in Merton and Morden may be gathered from the following facts: — 1. Inspection of Dwelling Houses during the year:— i. (a) Total number of dwellinghouses inspected for housing defects (under Public Health or Housing Acts) 761 (b) Number of inspections made for the purpose 761 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 400 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 335 42 3. Action under Statutory Powers during the year:— A:—Proceedings under Section 9, 10 and 16 of the Housing Act, 1936: — (i) Number of dwellinghouses in respect of which notices were served requiring repairs — (ii) Number of dwellinghouses which were rendered fit after service of formal notices: — (a) By owners — (b) By local authority in default of owners — B.—Proceedings under Public Health Acts: — (i) Number of dwellinghouses in respect of which notices were served requiring defects to be remedied 45 (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 33-38). 43 FACTORIES ACT, 1937. 1. Inspections for purposes of provisions as to health (including inspections made by Sanitary Inspectors). Premises Number on Register Number of Inspections Written Notices Occupiers prosecuted (i) Factories in which Sections 1, 2, 3, 4 and 6 are to be enforced by Local Authorities 21 18 2 - (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 174 228 18 - (iii) Other Premises in which Section 7 is enforced by the Local Authority 2 - - - Total 197 246 20 — 2. Cases in which defects were found. Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied To H.M. Inspector By H.M. Inspector Want of cleanliness (S.l) 4 4 — 1 — Overcrowding (S.2) — — — — — Unreasonable temperature (S.3) — — — — — Inadequate ventilation (S.4) — — — — — Ineffective drainage of floors (S.6) — — — — — Sanitary Conveniences (S.7) (a) Insufficient - - - - (b) Unsuitable or defective 24 19 — — — (c) Not separate for sexes 1 1 — 1 — Other offences against the Act (not including offences relating to Outwork) 2 2 - - - Total 31 26 — 2 — 44 SECTION F — INFECTIOUS ILLNESS. As was mentioned last year, our notification rates for Measles, Scarlet Fever, and Whooping Cough are higher than the figures for England and Wales, for the 126 great towns and for the Administrative County of London, while our figures for all other infectious diseases are the lowest in the comparative table. This is an interesting fact and I think that the answer is probably to be found not in a real higher incidence of these infectious diseases but in a higher percentage of notifications, for the reason that in our area medical advice is sought for these conditions more frequently and it is indicative rather of a higher standard of parental care than of any adverse environmental factors. Notification. The following diseases are notifiable in the District: — Cholera Acute Primary Pneumonia Cerebro-Spinal Fever Acute Influenzal Pneumonia Continued Fever Acute Poliomyelitis Diphtheria (including Acute Polio-Encephalitis membranous Croup) Puerperal Pyrexia Dysentery Relapsing Fever Enteric Fever (including Scarlet Fever paratyphoid fevers) Smallpox Erysipelas Trench Fever Encephalitis Lethargica Typhus Fever Food Poisoning Tuberculosis (all forms) Malaria Whooping Cough Ophthalmia Neonatorum Measles Plague Smallpox. There were no cases of Smallpox in our area during the year. The s.s. "Mooltan" in April provided the only contacts requiring surveillance. This ship, which had a fatal case of Smallpox on board, disembarked 10 contacts into our area. These were kept under surveillance until the expiry of the incubation period. Subsequently a further group of 5 contacts had to be kept under observation as a contact from a neighbouring district developed the disease. Enteric Fever. There were no notifications of Enteric or Typhoid Fever during the year, but there was a death assigned to us in the Registrar General's Transfer Lists. It was a resident of ours who was taken o2 a ship in the Port of London and admitted to a Fever Hospital, where she died. The onset appears 45 to have been two days after she had left Port on her way home to England, so that the source would appear to have been the country from which she embarked. Diphtheria. There were only two cases of Diphtheria during the year. This has broken last year's previous record of three, as last year's figure beat the figure of 5 which was the previous record. Neither of these cases was immunised. Both these arose as part of a small outbreak among the children travelling by special bus to the L.C.C. Special Schools. The search for the source became very complicated by reason of children being picked up at various points and by the necessity at one stage of changing from one bus to another. Eventually it was necessary to swab the whole of the children going to these schools. This could only be done by the co-operation of the L.C.C. School Medical Service, which was very generously given. In one of the families there were 5 other children of school age immunised and one not immunised ; all these others escaped. Scarlet Fever, There were 187 cases of Scarlet Fever notified during the year. 88 of these, or nearly half, arose in the Morden Ward, and as 73% of all cases are of school age, it is not surprising that a large number of cases in the Ward were school children, and as the majority of children in this Ward attend one school, attention was naturally focussed on this school. Obviously, opportunities for infection by contact occur throughout a school child's day, and the contact during play is perhaps much closer than during study. None the less, while we cannot take any very effective steps to limit the opportunities for spread by contact outside, in the school we can and a concentrated effort was made to secure that the opportunities for spread were kept to a minimum. Of all the measures taken my impression is that there are four primary aims to achieve in such circumstances. 1. To exclude other suspected infections. This is not always easy, the mother whose child has been sent home without being labelled with a familiar complaint is often very dissatisfied, and in these days when so many of them go out to work it is not unknown for them to send them back to school again accompanied by some unflattering observations. 2. Follow up the cases discharged from hospital so as to see them on their first day back in school. In the interval between their discharge quite well from hospital and their return to school a considerable proportion develop nasal discharges, and less frequently other recurrences of infectivity. 46 3. Reduce the more intimate grouping during lessons, or preferably cut it out altogether temporarily. In this particular school, which was a modern one both in education and outlook, this friendly, informal, intimate system was extensively practised. 4. The last of the four most important items is largely a matter for the parents, it is to obviate the attendance of early and missed cases. Last year I analysed the interval between the last attendance in school and the appearance of the rash. I found that 12 children were actually in school on the day of the rash, one was in school the day after as well, and one was even in school for two days after the rash had appeared. Bearing in mind that a child is infectious two days before the rash comes out, there is no need to look for an obscure source of infection when cases are loose among the school children. It is gratifying to be able to record that at the time of writing this report all these measures, together perhaps with a raised herd immunity, have succeeded in bringing the incidence of Scarlet Fever in this Ward to normal proportions. What part herd immunity plays in this story is impossible to discover, but it is interesting to observe that if one looks back a few years, one can see the same phenomena at work in other Wards with other schools as the storm centre. It is opportune here to record the cordial relations between the teaching staff and the department. Without the close co-operation of the head teachers, as well as the class teachers, our efforts could not be effective. Measles. There were 721 cases of Measles during the year. The biennial characteristic of Measles epidemics is now scarcely discernible, though reference to the table on page 48 will serve to remind us that it was at one time a clearly marked phenomenon. We have had almost epidemic numbers of cases every year since 1940. Measles continues to be a mild disease and it may be that we ought to be grateful that the incidence of this disease is high while it is so mild, as it thus maintains at a high level the immunity of the population. The report of the Ministry of Health for 1949 contains reference to an outbreak in one of the islands of the Dutch East Indies in 1948, where out of a population of 120,000 persons some 20,000 persons were attacked, with a death rate of 1 in 20. This seems to show that the virus of Measles under favourable conditions can still be an enemy not to be despised. Out of the 721 cases notified there were no deaths. In addition to losing its biennial characteristic there has been a rapid fall in fatality. These changes have attracted the 47 notice of epidemiologists and a detailed study of the disease in London has been made by the members of the London County Council's staff. The work has been published under the title " Measles in London ". This biennial period beat of a year of high prevalence followed by a year of low prevalence was true of London and other great cities in England before the war. Attention has been drawn to its absence in our own district in the reports since the War. I have thought it may have been due to the addition of the pre-school group when the disease became notifiable. Separate analysis of the incidence among the school children shows that this is not the case, it is in fact a genuine alteration in this characteristic of the disease. This change has not taken place everywhere, for in New York the disease continues to exhibit its biennial prevalence. INCIDENCE OF MEASLES 1930-1949. Year Cases Deaths Population Remarks 1930 295 3 35,000 School children only included — disease not being notifiable. Figures based on returns from Head Teachers. 1931 7 -— 41,510 1932 418 2 48.550 1933 14 — 52,130 1934 523 6 55,550 1935 5 — 57,440 1936 586 4 61.000 1937 86 — 65,530 1938 403 -— 68,980 1939 5 — 72,150 1940 459 1 68,540 Whole population included from 1940 when disease became notifiable. 1941 539 .— 64,920 1942 936 .— 66.590 1943 433 1 66,880 1944 252 1 62,760 1945 760 — 66,050 1946 568 -— 73,590 1947 347 •— 75,290 1948 1.049 — 75,220 1949 721 75,470 Whooping Cough. There were 331 cases of Whooping Cough notified during the year as compared with 378 last year. Although this disease was not responsible for any deaths in our area it is none the less a distressing and debilitating disease. Unfortunately, just when an effective remedy seems to be in sight, its safety has been called into question and in these circumstances, until a vaccine has been found with an efficiency of the order of Diphtheria preventatives, which have nearly a 100% success rate, few will feel that the value of the treatment justifies the risk. 48 Whooping Cough is probably one of the most inadequately isolated of all the infectious diseases. In the first place there is no rash to emphasize the presence of infectious disease, and secondly the disease in its early stages is quite difficult to diagnose clinically. Generally it is at a relatively late stage, after prolonged mixing with the general population, that it is eventually established. Even then it is doubtful if the public attitude to it is anything like as respectful as it is to the older fevers which were compulsorily isolated. Whatever are our views about the effectiveness of isolation as a means of controlling epidemics there can be no doubt that an infant is less likely to contract the disease if it is not exposed to the infection, and this is particularly important in the case of young children of 1 year and under in whom two-thirds of the total deaths from this disease occur, and half of these deaths take place in infants under six months. Q. Fever. During the year observation and follow up was undertaken on behalf of the Ministry of Health on three contacts of a case of Q. Fever which had occurred in a Laboratory of a London Hospital. Q. Fever is a Rickettial disease originally discovered in Queensland and now known to occur in various other parts of the world, but had not hitherto been suspected of existing in England. Food Poisoning. There were 8 notifications of Food Poisoning. The cases occurred in three groups. The groups were confined to small family outbreaks. 1. There were 3 cases in this group and extensive investigations failed to discover the source of the infection. Enquiries of nearby neighbours elicited the fact that one of the families had suffered a similar attack less than a week previously and at another that an assistant at one of the shops of supply in this case had similar trouble some time before. Enquiries at the shop failed to confirm this observation. Swabs were obtained from two of the cases but no pathological organism was isolated. 2. These were 3 cases in a family of four. The only member of the family to escape was the youngest child, aged 7. No item of food could be found which the family had consumed and the child had not consumed. It was said that he had had very little cold beef, which was one of the meals under suspicion. No pathological organisms could be found from rectal swabs. 3. This was one infection in a family outbreak. A particular child was notified, being the one who was worst affected. This outbreak followed a visit to what is regarded as one of 49 the more plebeian seaside resorts. The family of three were all affected more or less with diarrhoea and vomiting. In one of these cases B. Morgan No. 3 was isolated. No organisms were isolated from swabs taken from the other two members of the family. 4. This was a single infection. It was impossible to pursue our usual enquiries in this case as the victim was a traveller and ate at various food establishments around London and the particular meal of sausages which came under suspicion was eaten at an unknown restaurant. As will be seen, these are small family attacks of gastroenteritis. There have been no outbreaks involving any number of persons during the year. When we consider the number of canteens in the large factory estate where something hke 8,000 people are employed in 40 factories, and bearing in mind how common such outbreaks of food poisoning are at the present time in such canteens, it will not come amiss, perhaps, if we offer them our congratulations on their achievement. Dysentery. There were 3 actual notifications of dysentery during the year. In one attack it was said that a dog in the house had recently suffered from diarrhoea. A faecal swab was obtained from the dog and bacteriologically examined, but no pathogenic organisms could be isolated. Anterior Poliomyelitis. There were 15 notifications of Acute Poliomyelitis, 14 of whom were admitted to hospital. The diagnosis was confirmed in ten of these cases and amended in five instances. The tables set out on pages 52 and 53 will show in greater detail the story of their illness and its sequel. Of the ten established cases, four are known to have developed a degree of permanent paresis. There were no deaths in any of these cases. Erysipelas. There were 12 notifications of Erysipelas during the year, all of which involved the face. Seven occurred in males and five in females. Of the 12 cases notified, 8 were treated at home and 4 received hospital treatment. Ophthalmia Neonatorum. One case was notified during the year; recovery was complete and vision unimpaired. Pneumonia. There were 74 notifications of Pneumonia, of which twenty-five were stated to be influenzal in origin. The number of cases notified in the previous year was 40. 50 Puerperal Pyrexia. There were five notifications of Puerperal Pyrexia, giving a rate of 5.0 per thousand births. All these cases occurred in hospital, one being subsequently admitted to the Wandle Valley Isolation Hospital for treatment. In all cases the patients recovered. CLEANSING STATION. There was a further decrease in the number of attendances at the Cleansing Station during the year, the total being 128 as compared with 229 in 1948 and 445 in the year before. The details of the attendances during the year are as follows :— Number of cases of Scabies treated 43 Cases of Scabies with concurrent verminous head — Cases of Scabies with Secondary Septic Skin conditions Number of cases of verminous heads only 45 Total number of attendances at the Centre 128 51 ANTERIOR POLIOMYELITIS, 1949. Case No. Age. (Years) Hospital to which admitted Date of Onset Returned to Registrar General Confirmed by Hospital Hospital Diagnosis Sequel 1 16 Wandle Valley 23/1/49 Yes Yes Ac. Poliomyelitis No information. Patient has removed from this district. 2 11/2 Grove 3/6/49 Yes Yes Ac. Poliomyelitis No information. Patient has removed from this district. 3 18 Western 16/7/49 No No Myalgia 4 42 Wandle Valley 8/8/49 No No Disseminated Sclerosis 5 16 (Treated at home) 29/9/49 Yes - - Received therapeutic treatment at St. Helier Hospital until April, 1950. Fitted with built-up boots which he has now ceased wearing. Has slight dragging of right leg when fatigued. 6 16 Wandle Valley 11/10/49 Yes Yes Ac. Poliomyelitis No paralysis after discharge from hospital. Fully recovered. 7 1 Wandle Valley 15/10/49 Yes Yes Ac. Poliomyelitis Attended Physiotherapy Dept. of St. Helier Hospital for sunray treatment. Has slight paralysis of leftleg. Advised by Hospital to wear built-up shoes. 8 4 Cuddington 16/10/49 Yes Yes Ac. Poliomyelitis No paralysis left, now completely recovered. 52 Anterior Poliomyelitis 1949—cont. Case No. Age (Years) Hospital to which admitted Date of Onset Returned to Registrar General Confirmed by Hospital Hospital Diagnosis Sequel 9 14 Wandle Valley 17/10/49 No No Influenza 10 11 Wandle Valley 24/10/49 No No Tonsillitis 11 7 Croydon 20/10/49 Yes Yes Ac. Poliomyelitis No paralysis. Attended Physiotherapy Depts. at St. Helier and Nelson Hospitals. Now completely recovered. 12 1/1/2 Wandle Valley 2/11/49 Yes Yes Ac. Poliomyelitis Paralysis in left leg. Still attending St. Helier Hospital for heat massage and exercises. 13 4 Grove 1/11/49 Yes Yes Ac. Poliomyelitis Attended Physiotherapy Dept. of St. Helier Hospital for sunray and electrical treatment. Has slight paralysis of left side of face. 14 13 Wandle Valley 15/11/49 Yes Yes Ac. Poliomyelitis Complete paralysis of right leg and right hand ; slight paralysis of left leg. Is still in hospital for physiotherapy treatment. 15 12 Wandle Valley 30/11/49 No No Myalgia 53 TABLE X. Scarlet Fever — Monthly Distribution. Month Wards Total Abbey Bushey Mead Central Morden Park Ravensbury Raynes Park St. Helier West Barnes January 2 2 5 1 2 12 February 1 — 2 3 — 1 1 — 8 March — 3 3 4 1 3 1 15 April — 1 4 9 1 2 1 3 21 May — — 1 8 — 1 4 3 17 June 1 2 3 4 1 1 2 4 18 July — 7 2 1 1 3 10 August — — 1 4 1 1 5 12 September 1 I — 5 — 2 — 9 October — 2 1 19 1 1 1 25 November — 2 1 12 1 1 — — 17 December — 2 3 14 3 1 — 23 Total 5 14 23 88 11 3 19 2 22 187 Monthly mean 0.42 1.17 1.92 7.33 0.92 0.25 1.59 0.17 1.83 15.58 The incidence in the various wards was as follows: — Wards Cases Incidence per 1,000 population Abbey 5 0.9 Bushey Mead 14 1.7 Central 23 2.0 Morden 88 6.9 Park 11 1.0 Ravensbury 3 0.4 Raynes Park 19 2.2 St. Helier 2 0.2 West Barnes 22 2.8 54 TABLE XI. Infectious Diseases, Notifications, Deaths and Distribution, 1949. Disease Cases Notified Case Rate per 1,000 population Deaths among notified cases Percentage of deaths to cases Distribution of Cases in Wards No. of cases removed to hospital Percentage of cases removed to hospital Abbey Bushey Mead Central Morden Park Ravensbury Raynes Park St. Helier West Barnes Smallpox — — — — — — — — Scarlet Fever 187 2.49 5 14 23 88 11 3 19 2 22 129 69% Diphtheria 2 0.02 — 1 — — I — — — — 2 100% Enteric Fever - - - - - - - - - - - - - - - Cerebro-Spinal Meningitis 1 0.01 - - - - - - - - 1 - - 1 100% Puerperal Pyrexia 5 0.07 - - - - - - 5 - - - - 5 100% Erysipelas 12 0.15 — 2 1 4 — 2 1 2 — 4 33.3% Poliomyelitis 10 0.13 — 2 — 4 2 — 2 — — 9 90% Polio Encephalitis 2 0.02 1 50% — — — — 1 — 1 — — 1 50% Dysentery 3 0.04 — — — — 1 2 — — — — — — Food Poisoning 8 0.11 — — — — 6 — — 1 1 — — — Ophthalmia Neonatorum 1 0.01 - - - - - - 1 - - - - 1 100% Pneumonia 49 0.65 2 4.1% 2 3 9 5 9 3 7 6 5 * — Influenzal Pneumonia 25 0.33 2 8% 2 4 5 4 — 2 3 5 * .— Measles 721 9.55 — - 53 76 120 184 62 8 106 30 82 2 0.28% Whooping Cough 331 4.38 — — 22 28 24 98 34 29 24 53 19 2 0.60% *Number admitted to Isolation Hospital only. 55 TABLE XII. Notification of Infectious Diseases (other than Tuberculosis) by age groups during the year 1949. Disease TOTAL CASES NOTIFIED Total cases at all ages Under 1 year 1-3 3-5 5-10 10-15 15-25 25-35 35-45 45-65 65 and over Smallpox — — — — — — — — — — — Scarlet Fever — 13 32 122 14 6 — - — — 187 Diphtheria (including Membranous Croup) _ _ 1 1 - - - - - - 2 Enteric Fever (including Paratyphoid) - - - - - - - - - - - Puerperal Pyrexia — 2 1 2 — — 5 Acute Primary Pneumonia 1 __ 2 5 1 6 4 8 15 7 49 Acute Influenzal Pneumonia 1 1 _ 2 1 3 9 8 25 Cerebro-Spinal Meningitis - - - - - - - 1 - - 1 Poliomyelitis 1 2 2 1 1 3 — — — — 10 Acute Polio-Encephalitis - - - 1 - - 1 - - - 2 Encephalitis Lethargica — — — •— — — — — Dysentery — 1 — — — 1 1 3 Malaria — — — — — — — Ophthalmia Neonatorum 1 - - - - - - - - - 1 Erysipelas — — — — 1 1 10 — 12 Food Poisoning — — 1 — 1 3 3 — — 8 Relapsing Fever — — — — — — — — — Typhus Fever — — — — — — — — Measles 12 179 208 296 14 5 7 — — — 721 Whooping Cough 18 78 97 124 8 1 5 — — — 331 Totals 34 273 343 553 38 25 22 18 35 16 1357 56 TABLE XIII. Monthly Incidence of Infectious Disease, 1949. Disease January February March April May June July August September October November December Total Smallpox - - - - - - - - - - - - - Scarlet Fever 12 8 15 21 17 18 10 12 9 25 17 23 187 Diphtheria 2 — _ - - — - - - 2 Dysentery 1 — - - 1 - - 1 - - 3 Cerebro-Spinal Meningitis 1 1 Primary Pneumonia 6 11 7 6 1 4 3 1 7 3 49 Influenzal Pneumonia 2 8 8 3 - - 1 2 1 25 Food Poisoning 1 - - - - 3 3 1 - - 8 Erysipelas 3 — 1 3 1 2 - — 2 — 12 T.B. Pulmonary 4 7 8 7 18 9 4 6 3 7 6 7 86 T.B. Non-Pulmonary — — — 1 1 — 1 — — 3 — - 6 Ophthalmia Neonatorum - - - - 1 - - - - - - - 1 Puerperal Pyrexia — — 2 — — 1 1 — 1 — — — 5 Poliomyelitis 1 — — — — 1 — — — 5 3 — 10 Polio Encephalitis - - - - - - - - 1 1 — — 2 Malaria — — — — — — — — — — — — — Measles 77 207 190 55 67 72 33 4 4 9 1 2 721 Whooping Cough 54 67 33 28 20 19 23 13 9 19 27 19 331 Totals ... 163 308 264 124 126 129 80 36 28 72 64 55 1449 57 DIPHTHERIA IMMUNISATION. The tables on the succeeding pages show the scope and extent of the immunisations carried out last year. In comparing the figures for the under 5s with those for the previous year it is necessary to bear in mind that the material available, that is roughly the previous year's births, were only 1087 as against 1345 for the previous year. The total immunisations under 5 therefore for the year, expressed as a percentage of the live births for the previous year was 68.8% as compared with 68.3% last year. It is of interest that the number of immunisations in the 0-5 group carried out by the General Practitioners rises from 176 last year to 310 this year, that is from 19.6% of the total to 41.4%. Reference to table XVIII on page 61 gives an illuminating picture of the change that has taken place in the incidence and fatality of Diphtheria. The average number of cases for the 10 year period 1920-1929 is 41.3, for the next 10 year period 1930-1939 it is 45.3, and for the 10 year period just passed it has fallen to an average of 11.4 per year. We should be very careful, therefore, before we allow ourselves to be scared by the fear of the unknown into discouraging a tried and proved weapon such as Diphtheria immunisation. The National Health Service Act, 1946, did away with compulsory vaccination in infancy and our success now depends on the public enthusiasm for the measure as a precaution against Smallpox. During the year the following number of vaccinations were carried out: Vaccinations 469 Re-vaccinations 79 Of the above 305 were vaccinated by Private Practitioners. 189 of these vaccinations were primary vaccinations in infancy. VACCINATIONS. 58 TABLE XIV. Persons Immunised at Clinics during 1949. WARDS AGE GROUPS 0-5 years 5-15 years Total Completed Primary Total Single Boosting Injections Completed Primary Single Boosting Injections Completed Primary Single Boosting Injections Abbey 25 1 2 5 27 6 Bushey Mead 53 — 1 2 54 2 Central 46 2 2 7 48 9 Morden 68 4 3 7 71 11 Park 49 4 2 53 2 Ravensbury 36 — 3 36 3 Raynes Park 47 — 3 47 3 St. Helier 64 2 1 2 65 4 West Barnes 36 1 1 5 37 6 424 10 14 36 438 46 TABLE XV. Persons Immunised by Private Practitioners, 1949. WARDS AGE GROUPS Total Completed Primary Total Single Boosting Injections 0-5 years 5-15 years Completed Primary Single Boosting Injections Completed Primary Single Boosting Injections Abbey 9 - 2 _ 11 Bushey Mead 26 — 1 — 27 - Central 34 - 2 - 36 - Morden 73 19 2 11 75 30 Park 34 1 — 4 34 5 Ravensbury 13 - 1 1 14 1 Raynes Park 47 1 3 2 50 3 St. Helier 24 - 1 1 25 1 West Barnes 36 1 2 4 38 5 296 22 14 23 310 45 59 TABLE XVI. Children Immunised in Day Nurseries. Nursery Completed Middleton Road Morden Road 13 Total 13 TABLE XVII. Number of Children Immunised at Schools, 1949. School Incomplete Completed Primary Single Boosting Injections Bushey County Primary 4 16 72 Poplar Road County „ 6 9 57 St. Mary's „ „ —. 9 47 Merton Abbey „ 2 10 38 Hillcross „ „ 2 20 87 Raynes Park 4 25 78 Morden „ „ 7 10 42 Morden Farm „ „ 4 13 80 St. Helier No. 1 „ 1 11 87 St. Helier No. 2 „ „ — 12 31 St. Helier No. 3 „ 3 15 61 St. Helier No. 4 ,, „ 3 21 95 Holy Family R.C. Vol. Primary 1 19 32 Sacred Heart R.C. Vol. Primary 2 10 29 39 200* 836* Includes children attending schools in Merton and Morden but resident in other areas: — Primary ... 62 Boosters ... 140 202 60 The number immunised since the inauguration of the Public Clinics in 1934 is as follows: — At Clinics By Doctors In Schools At Day Nurseries Total 1934 93 28 — — 121 1935 375 19 — — 394 1936 383 13 664 — 1,060 1937 502 27 293 — 822 1938 376 22 260 — 658 1939 277 11 303 — 591 1940 234 12 50 — 296 1941 700 6 3,198 — 3,904 1942 1,127 16 753 — 1,896 1943 813 64 211 51 1,139 1944 515 54 216 28 813 1945 806 91 105 33 1,035 1946 726 72 488 34 1,320 1947 937 62 233 25 1,257 1948 722 176 246 25 1,169 1949 438 310 138 13 899 TABLE XVIII. Incidence and Fatality of Diphtheria, 1920-1949. 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 8 0.12 1 12.5 1945 66,050 12 0.18 1 8.3 1946 73,590 9 0.12 — — 1947 75,290 5 0.06 — — 1948 75.220 3 0.03 — — 1949 75,470 2 0.02 — — 61 62 TABLE XIX. Diphtheria Immunisation. Number of children 0— 5 years immunised January — June, 1949 403 Number of children 5—15 years immunised January — June, 1949 192 Number of children 0— 5 years immunised July — December, 1949 379 Number of children 5—15 years immunised July — December, 1949 15 Total number of children 0— 5 years immunised during the year 782 Total number of children 5—15 years immunised during the year 207 Number of children 0— 5 years immunised by Private Practitioners during the year 296 Number of children 5—15 years immunised by Private Practitioners during the year 14 Total number of children immunised by Private Practitioners during the year 310 Total number of children immunised in the Clinics during the year 438 Total number of children immunised in the Day Nurseries during the year 13 Estimated percentage of 0— 5 years immunised at end of year 55.91 Estimated percentage of 5—15 years immunised at end of year 86.18 Age Distribution of Immunised Children. Age at 31.12.49 i.e. born in year Under 1 1949 1 1948 2 1947 3 1946 4 1945 5 to 9 1940-44 10 to 15 1935-39 Total Immunised Estimated Population 0-5 Estimated Population 5-15 Total Population up to 15 Number Immunised 53 622 930 806 712 3,820 4,045 10,988 5,586 9,126 14,712 TUBERCULOSIS. One hundred and thirty one new cases were added to the register of tuberculous persons, compared with 119 in 1948. These additions were: — Males Females Total Pulmonary 73 45 118 Non-Pulmonary 5 8 13 78 53 131 Of these 131, 92 were primary notifications, 32 were transferred from other districts, and 7 came to notice in other ways. During the year 95 persons were removed from the register for the following reasons :— Recovered 4 Removed from the district 48 Death 43 After allowing for the additions and deductions, the number remaining on the register at the 31st December, 1949, was distributed as shown in the following table: — TABLE XX. Tuberculosis Register at 31st December, 1949. Wards Registered at 31st December, 1949 Totals Number on Register at mid-year Pulmonary NonPulmonary Abbey 50 10 60 60 Bushey Mead 66 15 81 81 Central 78 12 90 84 Morden 95 15 110 110 Park 114 20 134 132 Ravensbury 107 24 131 131 Raynes Park 67 8 75 78 St. Helier 167 35 202 191 West Barnes ... 54 21 75 72 Whole district 798 160 958 939 The provision of treatment and investigation of Tuberculosis is the responsibility of the Regional Hospital Board, the County Council being responsible for the preventive side 63 of the work. Institutional treatment was provided for 83 persons in 1949 from Merton and Morden, as follows :— At the County Sanatorium, Milford 15 At other Institutions 68 83 Many of us have been apprehensive of the effect of the present housing conditions on the incidence of tuberculosis. An additional table has therefore been prepared this year which shows in comparision the numbers of new cases for the past 10 years. The primary infections are all cases occurring in the district. The total cases include T.B. cases which have moved into the district and are added to our registers. It will be seen that the number of new cases arising within the district this year, although higher than last year, is in fact just below the average. TABLE XXI. Tuberculosis 1940-49. Year Primary Notifications Total New Cases Number on Register at end of year Pul. Non-Pul. Total Pul. Non-Pul. Total Pul. Non-Pul. Total 1940 59 15 74 94 24 118 442 104 546 1941 57 13 70 98 18 116 452 101 553 1942 93 14 107 127 24 151 514 112 626 1943 103 18 121 127 24 151 569 128 697 1944 87 10 97 127 13 140 620 133 753 1945 84 20 104 116 23 139 651 146 797 1946 72 13 85 101 18 119 671 147 818 1947 82 14 96 109 21 130 708 153 861 1948 74 11 85 104 15 119 761 161 922 1949 86 6 92 118 13 131 798 160 958 Total 797 134 931 1121 193 1314 — — — Average 79.7 13.4 93.1 112.1 19.3 131.4 — — — The deaths from Tuberculosis during the year number 30, of which 24 were due to pulmonary and 6 to non-pulmonarv disease. Seven of the deaths were in unnotified casess. 64 No action was taken under the Public Health (Prevention of Tuberculosis) Regulations, 1925, which give 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. The responsibility for maintaining the health of tuberculous persons in the district is undertaken by the Merton and Morden Tuberculosis Care Committee who assist patients, dependents and relatives in many ways, both financially and in kind, to secure extra nourishment, beds, bedding, clothing and household articles. They arrange for the provision of domestic help, assist in securing suitable employment, occupational therapy and rehabilitation and in the holiday schemes for child contacts in the family. I am indebted to the Secretary for the following information relating to the activities of the Committee during the year under review:— In many instances patients were assisted, with the help of the W.V.S., the S.S. & A.F.A., to obtain bedsteads, mattresses and bedding. Fourteen relatives and patients have received help with fares and nine patients received pocket money when in hospital or sanatoria. 65 The deaths are classified by age and sex in the following table: — TABLE XXII. Deaths Due to Tuberculosis, 1949. Years Pulmonary Non-Pulmonary Totals Males Females Males Females 0—• — — — — — 1— — — 1 — 1 5— — — — — — 15— 25— 3 3 1 1 8 35— 2 2 1 — 5 45— 2 — — — 2 55— 6 3 — 1 10 65— 3 — — 1 4 Totals 16 8 3 3 30 Grants were made to seventeen cases to enable patients, or their dependents, to secure clothing. The Committee has also assisted patients and their families in the following ways: — By payment of arrears of health insurance, and rental of flat. Maintenance of gas fire in bedroom and radio set. Part cost of spectacles. Holiday expenses to dependents. Provision of sun-lounge camp beds, thermos flasks, bedtables, sorbo air rings, back rests, ovaltine, etc. Camp holidays for child contacts. Materials for occupational therapy. Christmas gifts for children. Laundry bills paid while patients were on rest treatment. Provision of portable radio set for loan to patients. MASS RADIOGRAPHY. The Mass Radiography Unit made a second visit to Morden and was set up at the Baptist Hall from the 26th September to the 21st October. The response by factory managements to the invitation to allow their employees the necessary time to be dealt with in groups was most generous. Sessions were also reserved for school children over 14, and special sessions set aside for patients referred by General Practitioners in the area. There were also sessions for the general public to take advantage of the facilities on their own initiative. The appended table or statement shows the value and extent of the work done. Male Female Total Total number examined 1962 2362 4324 Pulmonary T.B., Active 5 7 12 Pulmonary T.B., Inactive 89 97 186 Abnormalities, non-T.B 89 72 161 66 The non-tuberculosis abnormalities comprise the following conditions:— Male Female Congenital abnormalities of bony thorax and lungs 12 16 Chronic bronchitis and emphysema 20 9 Bronchiectasis 3 2 Pulmonary fibrosis — non T.B. — 1 Obliterated costophrenic angle and basal pleural changes 39 28 Pleural thickening 3 3 Cardiovascular lesions — acquired (e.g. Rheumatic heart disease) 7 10 Acquired conditions of the ribs. (e.g. old resection and old rib fractures) 5 3 I am indebted to Dr. Walters, the Medical Director of the Mass Radiography Centre of the S.W. Metropolitan Region, for this detailed information, and I would like to take this opportunity of thanking him and Mr. Lewis, the Secretary, for their efforts in this achievement in our district and also for the invariable and ready co-operation in examining cases that are referred to them from time to time from the Ante-Natal and other Clinics in the area. 67 68 TABLE XXIII. 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 Pulmonary Non-Pulmonary Pulmonary Non-Pulmonary Pulmonary Non-Pulmonary new cases M F M F M F M F M F M F 0— 1 — — — — — — — — — — — — — 1— 5 2 1 — — — — — — — — — — 3 5—10 3 1 — — — 1 I 1 — — — — 7 10—15 2 1 — — — — — — — — — — 3 15—20 5 8 1 1 1 — — — — — — — 16 20—25 5 4 — 1 2 2 — — — — — — 14 25—35 6 10 2 1 8 5 1 2 1 1 — 1 38 35—45 13 4 — — 2 3 — — — — — — 22 45—55 6 — — — 2 — — 1 — — — — 9 55—65 8 2 — — — — — — — 1 — — 11 65 and over 5 — — — — — — — 2 1 — — 8 Totals 55 31 3 3 15 11 2 4 3 3 — 1 131 92 32 7 INDEX PAGE Acreage 6 Ambulance Facilities 26 Acute Poliomyelitis 50, 52, 53 Births 8-12 Institutional and Domiciliary 11 Rates 8, 12 Premature 25 Cancer—Deaths from 14, 17 Rate 16 Cinemas and Licensed Premises 40 Climatic Conditions 7 Cleansing Facilities 51 Contraceptives 31 Deaths 12-24 Causes of 13-21 Rates 12 Diphtheria 46 Immunisation 58 By age groups 62 Children immunised in Day Nurseries 60 Children immunised in Schools 60 Persons immunised in Clinics 59 Persons immunised by Private Practitioners 59 Incidence and fatality for 30 years 61 Drainage and Sewerage 31 Drainage work 33 Dysentery 50 Enteric Fever 45 Erysipelas 50 69 I N D E X-—Continued. PAGE Factories and Workplaces 6, 39, 44 Inspections 39 Defects 44 Food and Drugs Act, 1938 36, 37 Food Poisoning 49 Food Supply 30, 33 Inspections 33 Unsound Food 33 Health Services 26 Heart Disease—Deaths from 15, 17 Hospitals 28 Hospital Car Service 26 Housing 42-43 Action taken 33, 43 Inspections and Defects 32 Number inhabited 6 Overcrowding 42 Ice-Cream 38 Industry 6 Infant Mortality 8, 23-24 Causes of death 23, 24 Rates 8, 24 Infectious Diseases 45-57 Cases admitted to hospital . 28, 55 Diseases notifiable 45 Monthly Incidence 57 Notification by Age Groups 56 Notifications, deaths and distribution 55 Inquests 13 Isolation Hospital 28 Mass Radiography 66-67 Maternal Mortality 22 Rates 8, 22 Measles 47, 48 70 I N D E X—Continued. PAGE Meat Inspection 34 Mental Disease 29 Milk Supply 35 Mosquitoes 39 National Assistance Act 29 Nelson Hospital 28 Neonatal Deaths 23, 24 Notification of Births 10 Nuisance 32 Nursing in the Home 26 Ophthalmia Neonatorum 50 Population 8, 10 Pneumonia 50 Premature Births 25 Public Cleansing 31 Public Health Committee 4 Puerperal Pyrexia 51 Q. Fever .. 49 Rainfall 7 Rateable Value 6 Rats and Mice Destruction 40 Respiratory Diseases—deaths from 16 Representatives on:— North-Eastern Divisional Health Sub-Committee 4 Tuberculosis Care Committee 4 Wandle Valley Joint Sewerage Board 4 Rivers and Streams 31 Road Accidents—deaths from 15, 17, 20 Sanitary Circumstances 30-31 Sanitary Inspections, Summary of 41 Scarlet Fever 46-47, 54 Incidence in each Ward with rates 54 Monthly distribution of cases 54 71 IN D E X—Continued. PAGE Shops Acts, 1912-1936 40 Slaughterhouses 34 Smallpox 28 Smoke Abatement 40 Social Conditions of the Area 6 Staff 5 Statistics 7-8 Comparative 9 Tuberculosis 63-67 Admission to Sanatorium 64 Assistance given 65, 66 Care Committee 4, 65 Deaths due to 14, 65 Dispensary 27 Mass Radiography 66-67 New cases—by age groups 68 Number on register at end of year 63, 64 Venereal Diseases 27 Water Courses 39 Water Supply 39 Whooping Cough 48 Zymotic Disease—deaths from 8 Rate 8 72 Printed by RAYNES PARK PRESS, Lambton Road, LONDON, S.W.20. Tel. WIM. 1388.