ENF 1 THE Urban District Council of Enfield. ANNUAL REPORT OF THE Medical Officer of Health FOR 1904. Enfield: PRINTED BY JAS. W. HATCH AND SON. 1905. ANNUAL REPORT OF THE Medical Officer of Health FOR 1904. To the Chairman and Members of the Urban District Council of Enfield. Gentlemen, I beg to submit my annual report for 1904. I am informed that the number of inhabited houses in the middle of the year was as follows:— Town Ward 2156 Chase Ward 2168 Ordnance Ward 2400 Green St. Ward 2531 Total 9255 Allowing 5.37 persons to each house, as at the census of 1901, this gives a population 2 of 49,699. There were 102 more inhabited houses than in June, 1903, and 548 more inhabitants. Births. The births registered were:— Males, 745; females, 682: total, 1,427—giving a birth-rate of 28.7 per 1,000, which is just 2 per 1,000 more than last year. Deaths. The deaths registered were 641, giving an excess of births over deaths of 786, and a death-rate, after deducting 16 deaths of outsiders and adding 1 dying outside, of 12.89 per 1,000. Analysing the ages at death, there were 226 under 1 year of age. 88 between 1 and 5 years. 17 „ 5 „ 10 „ 11 „ 10 „ 15 „ 7 „ 15 „ 20 „ 14 „ 20 „ 25 „ 31 „ 25 „ 35 „ 29 „ 35 „ 45 „ 37 ,, 45 „ 55 „ 47 „ 55 „ 65 „ 59 „ 65 „ 75 „ 59 „ 75 „ 85 „ 16 over 85 „ The death-rate of children under 1 year per 1,000 births was 158.3, a considerable increase on the 113.4 of last year, and chiefly due to the great prevalence of epidemic diarrhœa in the middle of the year. 3 Classifying the causes of death, and giving the three preceding years for comparison, we have as follows:— 1904 1903 1902 1901 Specific Febrile or Zymotic Diseases 177 89 92 87 Parasitic Diseases 1 0 0 1 Dietic Diseases 4 3 2 0 Constitutional Diseases 107 98 95 68 Developmental Diseases 108 73 76 56 Local Diseases 192 275 298 264 Deaths from Violence 20 10 25 22 Deaths from ill-defined and non-specified causes 2 2 20 26 Total 641 550 608 524 The Zymotic death-rate was 3.5 per 1,000. The following table shows the deaths of residents from the chief zymotic diseases during the last five years:— 1904 1903 1902 1901 1900 Whooping Cough 18 19 7 7 15 Scarlatina 3 8 2 8 4 Diphtheria 1 6 4 7 25 Measles 6 13 4 13 5 Enteric Fever 3 4 13 9 11 Epidemic Enteritis 105 27 34 35 69 There were 29 deaths from cancer; 42 from 4 phthisis; 22 from other forms of tuberculosis. There were 51 deaths from diseases of the nervous system, 20 being due to apoplexy, 7 to meningitis, and 17 to convulsions. Diseases of the circulatory system caused 47 deaths, 29 being due to endocarditis. From diseases of the respiratory organs there were 59 deaths, 37 from bronchitis, 19 from pneumonia, and 2 from pleurisy. Diseases of the digestive system caused 21 deaths, of which 2 were due to cirrhosis of the liver, and there were also 4 from chronic alcoholism. There were 20 deaths from violence, of which 3 were due to suffocation by overlaying, and 3 were suicides. The cases of infectious disease reported were:— 1st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr. Total. Scarlatina 29 23 27 61 140 Diphtheria 15 15 13 10 53 Enteric Fever 2 6 5 3 16 Small Pox 0 0 1 0 1 Erysipelas 10 9 5 4 28 Puerperal Fever 4 0 0 1 5 Membranous Croup 1 0 0 0 1 Total 61 53 51 79 244 The following table shows the number of 5 cases of each infectious disease notified during the past five years:—  1904 1903 1902 1901 1900 Scarlatina 140 204 258 216 192 Diphtheria 53 47 45 76 107 Enteric Fever 16 22 48 33 52 Small Pox 1 2 102 3 0 Erysipelas 28 26 23 35 34 Puerperal Fever 5 1 2 1 0 Membranous Croup 1 0 0 3 1 Continued Fever 0 0 1 1 1 Total 244 302 479 368 387 These notifiable infectious diseases again show a considerable reduction, which is almost entirely due to the cases of scarlatina having been 64 fewer than in 1903, though it was, as usual, more prevalent during the last quarter of the year. Diphtheria has been slightly more prevalent, but not at all excessive. Enteric Fever has been still lower than last year and for many years past. Small Pox. The was only 1 case, and that in a non-resident. The case was removed to South Mimms Hospital, and there was no extension. This Council is joining with other Middlesex Councils to provide a joint small pox hospital. Epidemic Enteritis. There were 105 deaths due to this disease, though certified sometimes as epidemic diarrhoea, or zymotic diarrhoea. Nearly all were those of infants under two years of age. 6 There was 1 death in June, 33 in July, 68 in August, 7 in September, and 1 in October. There had been 5 in the first quarter of the year, thus making 115 deaths, in which I have included 11 deaths of infants, certified only as diarrhoea, but occurring during July and August, and indistinguishable from the prevailing epidemic. The district is not easily divided for registration purposes, so that the following figures only indicate roughly the localities most affected. Thus there were 32 deaths in Bush Hill Park, 32 in Ponders End, 21 in Enfield Lock and Wash District, 21 round about Lancaster Road, 7 in and about the Town, 2 at the Highway, and 1 at Freezywater. The months of July and August, in which nearly all the deaths occurred, were dry and very hot. The milk supply was very varied, and the epidemic could not be traced to any one source of milk supply, but there can be little doubt that the conditions under which the infants were fed were the cause of the mischief. At high temperature microbes develop in milk with extraordinary rapidity, while it is also possible that certain preservatives, added in larger quantities during very hot weather, may excite gastric irritation. Milk must in such weather always be heated nearly to boiling point before being given, while all utensils, bottles, tubes, etc., should be also scalded. I have no doubt that in some cases the entrance of the germs of disease and the cause of the disorder is by the use of the so-called " comforters," which are often in a filthy 7 condition; are thrown on the floor and replaced in the baby's mouth. I believe them to be responsible for diseases of infants of various kinds, and totally unnecessary, as it is only of recent years that they have been used. I made a special inspection of the dairies and milk farms. There is in most cases an effort made by special apparatus on the farms to preserve the purity of the milk supply, but the highest standard of cleanliness was not reached in every case, and it is impossible to guarantee that all precautions are always used. In more than one case I found the hands of the milkers dirty, though they "had been washed," and the ideas of cleanliness seemed to be primitive. It should also be said that in more than one case the proprietor evidently took great pains, and did all that is possible to ensure the purity of the milk. I have examined 11 samples of well water with the result that 2 were found to be unfit for drinking purposes. I have made 16 bacteriological examinations for various medical men in the district in doubtful cases of diphtheria. Such examinations have in several cases shown that throats presenting the appearance of diphtheria were septic sore throats only. I inspected 2 houses in Carterhatch Lane and reported them as unfit for habitation; they have since been closed by magistrates' order. As the sewage works at Ponders End have for a long time been in an unsatisfactory 8 tion, and in view of the rapid increase of population, new arrangements have been made and sanctioned by the Local Government Board. I give a description of these arrangements supplied me by the Surveyor. SEWAGE DISPOSAL WORKS. The sewerage system of the District is divided into two, viz.:—the high level and the low level, the high level taking the drainage of practically the portion of the District West of the Hertford Road, and the low level the East of the Hertford Road, including all on the North side of the Turkey Street Brook. The sewage from the high level is discharged onto the Sewage Farm by gravitation into a Receiving Chamber near the boundary of the Edmonton and Enfield Districts, at the nearest point on the Farm to the Hertford Road. The sewage then either passes through the tanks formed in the ground in which septic action takes place, and then distributed on to the land, or on to the land direct. This sewage is dealt with mostly on the land West of the main line of the Great Eastern Railway, the effluent after passing through the land passes into the East London intercepting ditch. But there are two iron pipes—15-inch and 12-inch diameter respectively; these pass over the East London intercepting ditch, and under the Great Eastern Railway, and discharge the sewage by an open carrier on to the filter 9 beds on the Northern portion of the Farm, East of the Railway. The high-level dry weather flow is about 500,000 gallons per 24 hours. The sewage from the low level is discharged into either one or the other or into both of the two concrete grit chambers in which the heavier substances are deposited. The sewage then passes into the two open concrete precipitation tanks (in which the sewage is liquified), then into the storage tanks, and from thence to a sump well, and is pumped into the carriers to be distributed onto the land, the effluent discharging into a watercourse running parallel with the River Lee Navigation, through the Edmonton Sewage Farm, before joining a stream which discharges into the River Lee Navigation. The East London Cut also discharges into the same stream. The dry weather flow of the low level is about 500,000 gallons per 24 hours. The new works, for which the Local Government Board are asked to sanction the expenditure of £7,500 from the money the Council will receive from the Metropolitan Water Board, are needed in consequence of the present machinery (engines, pumps, and boilers)—which have been in use about 27 years—not being equal to the present requirements; and the area of land for sewage disposal by the present method is hardly sufficient for the effectual treatment of the sewage, and are as follows:— The Erection of a Pumping Station.— Install therein 3 gas engines, 3 centrifugal pumps, and 3 gas producers of the Suction type, all to 10 be of equal power and interchangeable, each separate set capable of dealing efficiently with a minimum supply of 50,000 gallons per hour (which is the present estimated dry weather How from both the high and the low level systems), or 1,250,000 gallons in 24 hours, and if working with a slightly increased speed, will deal with a somewhat larger amount, say 60 or 70,000 gallons per hour, or 1,500,000 per day. The working of the plant would be as follows The normal flow of sewage would be dealt with by the one set: when the flow increased beyond the capacity of the one, the second set would be brought into use, the two sets dealing with a maximum of, say, 3,000,000 gallons per day, or three times the dry weather flow; the third set would be a standbye, yet at the same time any part of this set could be used, being interchangeable with the other two sets. The sewage, as at present, will pass through the existing detritus chambers, sedimentation tanks, and storage tanks; the tank effluent passing into sumps will be lifted by the new pumps into a receiving take (or over a U pipe) from which it will flow by gravitation onto the three circular filters, each being 100ft. in diameter, with filtering medium not less than 7ft. in depth, the delivery of the effluent being regulated by proper valves, and discharged on to the filters by self-acting, revolving sprinklers. The effluent, after passing through the filtering medium, ventilating and draining tiles, the collecting 11 channel, and along the existing carriers, will be discharged onto the land. After passing through the land the effluent will be discharged into the intercepting ditch, and from thence into the River Lee below the intake of the East London Water Company (Metropolitan Water Board), consequently not mixed with the water supplied to consumers. The filters will, it is estimated, deal efficiently with 1,000,000 gallons of tank effluent (the dry weather flow) per day, the quantity beyond this in time of rain will be discharged from the receiving tank before mentioned by an overflow main, and conveyed through a new carrier, and along the existing carriers onto the land. Under the new Act of Parliament the wells and water supply have been handed over to the Metropolitan Water Board. The water supply has been ample and of good quality. Several roads have been widened or paved and footpaths tar-paved. The following private streets have been made up and adopted:—Falmer and Cross Roads, Bush Hill Park; Uckfield and Titchfield Roads, Enfield Lock; part Holmwood Road, Freezywater; and Alma Road, Ponder s End. Sewers have been laid at Cockfosters, Camlet Way, Oak Avenue, Ridgeway; and in Hadley Road. A 9in. surface water drain has been laid at Clay Hill, and a 3ft. storm-water culvert at Bush Hill Park. 12 THE ISOLATION HOSPITAL The number of cases received during the year was 458. Of these, 161 belonged to this district, and the remaining 297 belonged to other districts, as follows:— Edmonton 183 Wood Green 78 Cheshunt 16 East Finchley 8 Friern Barnet 7 Waltham Holy Cross 5 Of the 458 cases received, 278 were cases of scarlatina, 144 of diphtheria, and 27 of enteric fever. There were 9 other cases, of which 2 were fatal cases of measles, dying on the sixth day, in which there had probably been a scarlatiniform "prodromal" rash, as it is called: 1 of these was also suffering from heart disease. A third case was 1 of German measles, and the rest were 1 each of nephritis, pneumonia, meningitis, general tuberculosis, influenza, and myoma of the uterus. Of the 278 cases of scarlatina, 274 recovered and 4 died, a case-mortality of 1.4 per cent. One of these was on the point of discharge and died of croup and bronchitis. Many of these cases were severe and complicated with nephritis, otorrhœa, and rhinorrhoea, etc. The average number of days in hospital was 50'2 Of the 144 cases of diphtheria, nearly all having the specific bacillus as shown by bacteriological examination, 136 recovered and 8 died: 13 this gives the very low case-mortality of 5.5 per cent. But of these, 3 died within 24 hours of admission, and 1 of them 2 hours after admission. These might with justice be omitted from the calculation. The average number of days in hospital was 22.3. Of the 27 cases of enteric fever 5 died, a case-mortality of 18.5 per cent., which is slightly above the average: 1 of them suffered from chronic Bright's disease, and 1 died from profuse haemorrhage. One died within 2 days of admission, and some of the others were sent in at a very advanced stage of the disease at considerable risk. The average number of days in hospital was 33.6. The average daily number of patients was 48.724; the average daily number of the nursing and domestic staff was 26.14; and the average daily cost of food for patients and staff was 85/8d. Negotiations have been concluded for the formation of a Joint Hospital Board with the Edmonton District Council to take over the hospital, and a Provisional Order is being applied for to effect this. The following is the report of the work done in the Sanitary Department under Mr. A. J. Munro, the Sanitary Inspector:— Inspections:— Houses inspected from house to house 601 Other houses and premises inspected 1,514 23 factories inspected 23 136 workshops and workplaces, including 8 laundries (inspected 14 quarterly): total number of inspections 538 36 bakehouses (inspected frequently): total 262 16 slaughterhouses (inspected frequently): total 223 32 cowsheds (inspected frequently): total 196 64 dairies and milkshops (inspected frequently): total 335 26 schools (inspected twice): total 56 Other inspections made while works in progress, also visits in connection with cases of infectious disease, etc. 9,365 Smoke observations made 95 Total number of inspections 13,208 Notices issued:— For repairs to drains and abatement of nuisances 257 Under Infectious Diseases Act:— To occupiers 102 To schools 1,108 Total number of notices issued 1,467 Letters sent:— In lieu of notices 668 Other letters 1,462 Total 2,130 15 Houses and parts of houses cleansed, repaired, etc. 247 Houses closed by owners as beyond repair 3 Roofs repaired 192 Gutters and downpipes repaired 150 Cesspools emptied 253 Cesspools abolished 7 Houses connected with sewer, and new drains constructed 34 House drains cleared, repaired, etc. 252 House drains tested, examined, etc. 208 House drains reconstructed 133 Manholes provided on drains 63 Soil-pipes and drains ventilated 84 Ventilating pipes repaired 31 Fresh air inlets repaired 53 Waste pipes repaired 10 Rain-water pipes and waste pipes disconnected from drains 13 Closets provided with flushing cisterns or water supply 33 Flush cisterns put in order 362 New closets provided 15 Closets repaired, cleansed, etc. 96 Houses provided with proper water supply 26 Storage cisterns repaired, covered, cleansed, etc. 134 New storage cisterns provided 17 Yards paved 166 Paving over yards made good 51 New dustbins provided 232 Dustbins repaired 11 Manure heaps removed 55 16 Fowls and other animals removed 30 Cases of overcrowding abated 16 Houses fumigated 187 Rooms stripped, etc. 52 Articles of clothing and bedding, etc., disinfected 1,730 Library books disinfected 64 Cases of scarlet fever removed to hospital 111 Cases of diphtheria removed to hospital 38 Cases of enteric fever removed to hospital 8 Cases of small Pox removed to hospital 1 Total 158 Gipsy vans removed 31 Ventilation provided under floors 70 Dampness in walls remedied 13 Other nuisances abated 37 Articles or parcels of unsound food destroyed 20 The removal of house refuse has received close attention, and 4,826 loads have been collected and disposed of. Factory and Workshops Act, 1901. A register of all workshops is kept, and at the end of 1904 there were 128 workshops, 8 laundries, and 36 bakehouses (including 1 underground bakehouse) registered. These have all been inspected at least four times in the year, and the following contraventions were found requiring action which was taken. 17 Workshops. Cases of overcrowding abated 3 W.c.'s with defective flushing 18 Cleansed and limewashed 6 Provided with proper closets 2 Floors repaired 3 Dustbins provided 2 Drains cleared 2 Factories. Sanitary conveniences put in order 3 Bakehouses. W.c.'s with defective flushing remedied 9 Cleansed and limewashed 20 Floors repaired 2 Dustbins provided 3 Homework. Lists received enclosing 33 addresses of outworkers 5 Addresses of outworkers received from other districts 7 Addresses of outworkers forwarded to other districts 11 An inspection was made of the residences of all outworkers living in this district. Two notifications have been sent to H.M. Inspector of Factories of workshops where abstract not fixed. One notification received from H.M. Inspector of Factories of matters requiring attention. Report of action taken afterwards sent to H. M. Inspector. 18 UNSOUND FOOD. During the year a regular inspection has been made of meat slaughtered and offered for sale in the District, including the stalls in markets at R.S.A. Factory and Enfield Town, every week. Fifteen parcels of organs found to be affected with disease were surrendered by the owners, and with their permission destroyed. The following articles were also brought by the owners to the office and certificates obtained which the retailer might present to the wholesale trader as a guarantee of the bad condition of the articles when requesting to be reimbursed the amount paid for them, viz.:— 2 casks of fresh herrings. 1 box haddock and whiting. 2 boxes haddock. A. J. MUNRO, Inspector of Nuisances. Yours obediently, J. J. RIDGE, M.D. and M.D. (State Medicine) B.S., B.A., B.Sc. Lond., L.R.C.P. Lond., M.R.C.S. Eng., Medical Officer of Health and Medical Superintendent of Enfield Isolation Hospital.