ENF 3 THE URBAN DISTRICT COUNCIL OF ENFIELD. ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH, FOR 1908, together with the ANNUAL REPORT of the INSPECTOR OF NUISANCES. ANNUAL REPORT of the Medical Officer of Health. FOR 1908. To the Chairman and, Members of the Urban District Council of Enfield. Gentlemen, I have the honour to present my first Annual Report, and in doing so, would ask your kind consideration for the faults and shortcomings you will no doubt discover in it ; I would ask you to remember that in succeeding a man of such brilliant and varied attainments as your late Medical Officer of Health, Dr. J. J. Ridge, I was undertaking a task that I fear I should have been incapable of carrying out with any measure of success, had it not been for the uniform and constant kindly consideration I have at all times received at your hands. In June, your Council had the misfortune to lose by a premature death its Medical Officer, Dr. J. J. Ridge, who had served it well and faithfully for many years, consequently the year is divided into three periods, January to June; June and July, when Dr. E. M. Ridge was Acting 2 Medical Officer of Health; and August 1st onwards, when I commenced my duties, but by arrangement with Dr. E. M. Ridge, I have included the statistics for the whole year in this report. The year 1908 has proved to be an anxious one. Shortly after my term of office commenced an outbreak of Diphtheria appeared, which threw great strain both on your Sanitary officials and on the Hospital accommodation, but I think 1 may fairly claim that all the difficulties were successfully met. A copy of my special Report on the Diphtheria epidemic is included at the end of this report. Population. The population of Enfield as ascertained at the last census of 1901 was 42,738, and the estimated population in the middle of 1908 was 56,185. The total area of the district is 12,600 acres, until recently divided into five wards. The number of houses is as follows — Inhabited. Uninhabited Total. Town Ward 1346 78 1424 Chase Ward 2431 225 2656 Ordnance Ward 1961 179 2140 Green Street Ward 2526 167 2693 Bush Hill Park 2238 124 2362 10,502 773 11,275 showing an increase on the previous year of 382 houses, with a decrease of 36 uninhabited ones. 3 Births. The number of births registered was:— Boys. Girls. Total. 734 686 1420 giving a birth-rate of 25'18 per 1,000. The birth-rate for the three previous years was 1905, 26.44. 1906, 25.45. 1907, 26.18. Deaths. 621 deaths were registered as occurring in , the district during the past year, 320 being those of males and 301 females. To these must be added 64 deaths of residents of Enfield registered outside the district; and 60 deaths of nonresidents occurring in the district must be subtracted, giving a total of 625 deaths. This gives a recorded death-rate of 11.18, and a death-rate corrected for age and sex distribution of 1176 per 1,000. The corresponding figures for the last three vears were:—Recorded death-rate, 1907, 12.3; 1906, 11 2; 1905,. 11 1. Corrected death-rate, 1907, 12*9; 1906, 11.7; 1905, 11.67. blassitvmg the 621 deaths registered in Enfield, according to their sex and age, we have the following table:— Male. Female. Total. Under 1 year 73 55 128 1 to 5 years 38 38 76 5 to 10 years 17 23 40 10 to 15 years 6 3 9 15 to 20 years 10 2 12 20 to 25 years 6 5 11 25 to 35 years 12 16 28 4  Male. Female. Total. 35 to 45 years 12 15 27 45 to 55 years 24 30 54 55 to G5 years 30 31 61 65 to 75 years 43 44 87 75 to 85 years 37 35 72 Over 85 years 12 4 16 320 301 621 Infantile Mortality. The death-rate of children under 1 year was 90 14 per 1,000 births. This is very considerably lower than has obtained in Enfield for some years, the death-rate in 1905 being 117.17; in 1906, 1057; in 1907, 116.6. This low mortality is chiefly due to the small amount of epidemic Diarrhoea which occurred during the summer. The continual rain which fell in July and August, the two months when Diarrhoea is usually most prevalent, probably contributed to this by preventing clouds of germ-laden dust flying about, contaminating milk and food, and conveying disease to those small and youthful members of the community who are least able to resist it. In connection with the death of old people, it is worthy of note that one death of a male was registered at over 100 years. The deaths for the last ten years will be found in Table I. The various causes of death during 1908, are set out in Tables IV. and V., the latter of which refers to deaths under 1 year. TABLE I. Vital Statistics of Whole District during 1908 and previous Years. Year. Population estimated to Middle of each Year. Births. Total Deaths registered in the District. Total Deaths in Public Institutions in the District. Deaths of Nonresidents registered in Public Institutions in the District. Deaths of Residents registered in Public Institutions beyond the District. NETT DEATHS AT ALL AGES BELONGING TO THE DISTRICT Number. Rate. Under 1 Year of Age. At all ages. Number. Kate per 1000 Births registered. Number. Rate Number. Rate. 1 2 3 4 5 6 7 8 9 10 11 12 13 1898 39,360 1,137 28.1 179 157.0 530 13.46 40 - - - - 1899 40,289 1,155 28.6 203 175.0 613 15.2 48 - - - - 1900 43,394 1,186 27.0 172 145.0 614 13.7 71 9 - 605 13.7 1901 43,000 1,232 28.6 110 89.3 524 12.2 - - — 524 12.18 1902 44,162 1,354 30.6 174 1271 608 13.5 - 12 - 596 13.5 1903 49,151 1,313 26.7 149 113.4 550 11.1 70 9 — 541 11.0 1904 49,699 1,427 28.7 226 1580 641 1.2.8 67 16 1 626 12.8 1905 51,315 1,357 26.4 159 117.0 532 10.6 60 12 50 570 11.1 1906 52,797 1,334 25.2 148 110.0 579 10.9 90 36 51 594 11.2 1907 54,688 1,432 261 167 116.0 614 11.4 24 9 62 639 11.68 for years 1898. 46,785 1,292 27.4 168 130.78 587 12.48 - - - - - 1907 1908 56,185 1,420 25.18 134 90.1 621 11.05 131 60 64 625 11.18 *Rates in Columns 4, 8, and 13 calculated per 1,000 of estimated population. Area of District in acres (exclusive of area covered by water), 12,600. Total population at all ages, 42,738; Number of inhabited houses, 7,988; Average number of persons per house, 5 37, at Census of 1901. 6 TABLE II. Vital Statistics of separate Localities in 190S and previous years. Year. Population estimated to middle of each year. Births registered. Deaths at all ages. Deaths under 1 year 1898 39,360 1,137 530 179 1899 40,289 1,155 613 203 1900 43,394 1,186 605 172 1901 43,000 1,232 524 110 1902 44,162 1,354 596 174 1903 49,151 1,313 541 149 1904 49,699 1,427 626 226 1905 51,315 1,357 570 159 1906 52,797 1,334 630 148 1907 54,688 1,432 639 167 Averages of Years 1898 to 1907. 46,785 1,292 587 168 1908 56,185 1,420 625 134 7 TABLE III. Cases of Infectious Disease notified during the Year 1908. Notifiable Disease] Cases Notified in Whole District. At all Ages At Ages—Years. Under 1 1 to 5. 5 to 15. 15 to 25. 25 to 65. 65 and upwards. Total cases removed to Hospital. Small-pox 0 — - - - — — 0 Cholera 0 - - - - - - 0 Diphtheria (including Membranous Croup) 371 2 85 233 30 21 — 270 Erysipelas 36 1 — 2 3 25 5 0 Scarlet Fever 202 — 43 134 18 7 — 172 Typhus Fever 0 — — — — — — 0 Enteric Fever 5 — — 1 — 4 — 0 Relapsing Fever 0 — — — — - — 0 Continued Fever 0 - - - - - - 0 Puerperal Fever 3 — — — 1 2 — 0 Plague 0 - - - - - - 0 Totals 617 3 128 370 52 59 5 442 TABLE IV. Causes of, and Ages at, Death during Yeah 1908. Causes of Death. Deaths at the subjoined ages of ' Residents ' whether occurring in or beyond the District. Total deaths whether of 'Residents' or 'NonResidents' in Public Institutions in the District. All Ages. Under 1 year. 1 and under 5. 5 and under 15. 15 and under 25. 25 and under 65. 65 and upwards. Small-pox ... ... ... ... ... ... ... ... Measles 6 ... 5 1 ... ... ... ... Scarlet Fever 5 2 3 ... ... ... ... Whooping-cough 3 1 2 ... ... ... ... Diphtheria (including branous Croup) ... ... ... ... ... ... ... ... 31 2 14 12 1 2 ... ... Croup 1 ... ... 1 ... ... ... ... Typhus ... ... ... ... ... ... ... ... Fever Enteric 1 ... ... ... ... 1 ... ... Other continued ... ... ... ... ... ... ... ... Epidemic Influenza 11 ... 1 ... ... 5 5 ... Cholera ... ... ... ... ... ... ... ... Plague ... ... ... ... ... ... ... ... Diarrhtea 27 22 4 ... ... ... 1 ... Enteritis 4 4 ... ... ... ... ... ... Puerperal Fever 2 ... ... ... 1 1 ... ... Erysipelas 1 ... ... ... ... ... 1 ... Phthisis 46 ... 1 3 9 29 4 ... Other tuberculous diseases 19 3 6 4 5 1 ... Cancer, malignant disease 43 ... ... ... 2 26 15 Bronchitis 79 22 13 ... ... 15 29 Pneumonia 27 4 5 1 1 10 6 Pleurisy ... ... ... ... ... ... ... ... Other diseases of Respiratory ... ... ... ... ... ... ... ... organs 2 ... 2 ... ... ... ... ... Alcoholism 6 ... ... ... ... 6 ... ... Cirrhosis of Liver ... ... ... ... ... ... Venereal Diseases ... ... ... ... ... ... ... Premature Birth 21 21 ... ... ... ... ... ... Diseases and Accidents of ... ... ... ... ... ... ... Parturition 1 ... ... ... ... 1 ... ... Heart Diseases 58 ... ... 1 1 27 29 ... Accidents 22 3 ... 1 11 7 ... Suicides 6 ... ... 1 4 1 ... Hemiplegia 30 ... ... ... ... 7 23 ... Old Age 40 ... ... ... ... 40 ... Nephritis 19 1 11 7 Diabetes 9 ... ... ... ... 7 2 ... Other Septic Diseases 1 ... ... ... ... 1 ... ... All other causes 104 55 3 5 5 30 6 ... All Causes 625 134 62 31 27 195 176 131 TABLE Y. Infantile Mortality during the Year 1908. Deaths from stated causes in Weeks and Months under One Year of Age. CAUSE OF DEATH. Under 1 Week. 1-2 Weeks. 2-3 Weeks. 3-4 Weeks Total under 1 Month. 1-2 Months. 1 2-3 Months. 3-4 Months. 4-5 Months. 5-6 Months. 6-7 Months. 1 7-8 Months. 1 8-9 Months. 9-10 Months. 10- 11 Months. ll 12 Months. | Total Deaths under One Year. All Causes. Certified Uncertified 27 11 5 6 49 17 10 11 9 7 7 10 7 1 3 3 134 i. Common InfectiousDiseases. Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Chicken-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria (including Membranous Uroup) ) ... ... ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 2 Whooping Cough ... ... ... ... ... ... ... 1 ... ... ... ... ... ... ... ... 1 ii. Diarrhoeal Diseases. Diarrhoea, all form ... ... ... 2 2 3 4 2 2 3 3 2 1 ... ... ... 22 Enteritis. Muco-enteritis ... ... ... ... ... ... ... 1 ] ... ... 1 .. ... 1 4 Gastro-enteritis Gastritis, Gastrointestinal Catarrh ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... iii. Wasting Diseases. Premature Birth 15 1 2 ... 18 2 ... 1 ... ... ... ... ... ... ... ... 21 Congenital Defects 5 1 2 ... 8 1 ... ... ... ... ... ... ... ... 9 Injury at Birth 2 ... ... 2 ... ... ... ... ... ... ... ... ... ... ... 2 Want of Breast-milk, ... ... ... ... ... ...1... ... ... ... ... ... ... ... ... ... ... 1 Starvation Atrophy, Debility 3 1 9 2 1 3 1 1 ... ... ... 28 Marasmus iv. Tuberculous, Diseases. Tuberculous Meningitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tuberculous Peritonitis: ... ... ... ... ... ... ... ... 1 1 ... ... ... ... ... ... 2 Tabes Mesenterica Other Tuberculous ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... v. Other Causes. Erysipelas ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Meningitis(not Tuberculous) ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ...1... ... 2 Convulsions 1 1 1 1 4 1 1 1 1 Bronchitis Laryngitis 1 1 2 4 2 1 2 1 1 4 2 2 1 22 Pneumonia ... ... 1 1 ... ... 1 ... ... ... 2 ... ... ... ... 4 Suffocation, overlying ... 1 ... ... 1 ... ... 1 ... ... ... ... ... ... ... 2 Other Causes 1 1 2 2 4 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 27 11 5 6 49 17 10 11 9 7 7 10 7 1 3 3 134 Population, estimated to middle of 1908, .36,185. Rirths in the year in the year legitimate, 1,385. Deaths in the year of ' legitimate infants, 132. legitimate 35 Deaths in the year of ( illegitimate infants, 2. Deaths from all Causes at all Ages, 625. 10 Zymotic Diseases. The following table shows the deaths registered in the district from the 7 chief zymotic diseases during the past five years:— 1904 1905 1906 1907 1908 Small Pox 0 0 0 0 0 Whooping Cough 18 15 7 12 3 Scarlatina 3 4 7 15 16 Diphtheria 1 2 6 15 53 Measles 6 12 11 10 6 Enteric Fever 3 0 3 1 2 Epidemic Enteritis 105 36 66 20 4 136 69 100 73 84 The zymotic death-rate, after deducting 34 deaths of persons from outside this district who died in the Isolation Hospital is .88 per 1,000 for 1908. Notification of Infectious Diseases. The cases of infectious disease reported each quarter were as follows:— 11 1st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr. Total. Total number of cases per 1000 population. Scarlatina 54 28 37 83 202 ... Diphtheria 31 37 65 236 36!) ... Membranous Croup 1 0 0 1 2 ... Enteric Fever 0 1 2 2 5 ... Small Pox 0 0 0 0 0 ... Erysipelas 16 7 7 6 36 ... Puerpural Fever 2 0 1 0 3 ... 104 73 112 328 617 10.98 The following table gives the number of cases of each infectious disease notified during the past 5 years:— 1904 1905 1906 1907 1908 Scarlatina 140 194 259 353 202 Diphtheria 53 39 56 83 369 Membranous Croup 1 0 2 1 2 Enteric Fever 16 9 24 10 5 Small Pox 1 1 0 0 0 Erysipelas 28 31 45 30 36 Puerpural Fever 5 1 2 1 3 244 275 285 478 617 12 The following cases were removed to the Enfield and Edmonton Joint Isolation Hospital:— Scarlet Fever 172 Diphtheria 261 Enteric Fever 0 433 In addition to the above, nine cases of Diphtheria were removed to the Cheshunt Isolation Hospital. As mentioned in my special Report, I made 306 bacteriological examinations of swabs sent me by different medical men, in 128 of which I found the Kleb's Loftier Bacillus. I received a number of swabs of "Contacts" from the School Medical Officer, and though in the large majority of cases these proved to be non-specific, still some "carrier" cases were detected, promptly isolated, and prevented doing further harm; thus showing the advantage of such examinations, as it would have been next to impossible to diagnose some of these cases otherwise. I also examined some blood by the Widal test, from a suspected case of Enteric Fever, which showed that the patient was suffering from that disease. Method of Disinfection.—Rooms, etc. Rooms are sprayed with formalin and 13 fumigated with Formalin gas or sulphur. Owners or occupiers are also required to strip and cleanse rooms in all cases where patients have been isolated at home, or where otherwise necessary. Bedding and other articles that cannot be properly washed and boiled are disinfected in a Washington-Lyons steam disinfecting apparatus. This apparatus stands at the Council's sewagefarm. Two vans are used, one for conveying the infected articles from houses to disinfecting station, and the other for returning them. Water Supply. With the exception of Hadley and Cockfosters, which derive their supply of water from the mains of the Barnet Gas and Water Company, the District is almost entirely supplied by the Metropolitan Water Board. There are, however, some private surface wells still in use. I examined 8 samples from these, and found 3 unfit for drinking and domestic purposes. In these latter cases steps were taken to close the well and provide a supply from the Water Board's mains. Milk and Foods. As will be seen by reference to my special Report, particular attention has been paid to the milk supply this year. 14 Regular inspections, the particulars of which are set out in the report of the Inspector of Nuisances, have been made of cowsheds, dairies and milkshops, also slaughter-houses and bakehouses, while a close watch was also kept on the meat slaughtered, and sold in the district. I have made many visits to the above places to see for myself that the byelaws and regulations are enforced. Sewerage. A sewer has been laid in Lavender Hill during the past year. An additional filter is about to be constructed at the Sewage Farm, the same size as the existing filters (100 feet diameter). This is simply awaiting the approval of the Local Government Board. Mr. R. Collins, the Council's Surveyor, also informs me that a new 24in. and 18in. surface water drain has been laid from Duck Lees Lane outfall at the Great Eastern Railway level crossing to Hertford Road, via Nags Head Road, to accommodate that portion of Ponders End. A new culvert now being constructed in Cecil Road, Sarnesfield Road, Church Street and Little Park, is approaching completion. This will greatly accelerate the speedy removal of storm water from the neighbourhood referred to. 15 Private Roads and Streets. The following private roads have been made or laid out: The Chine, Winchmore Hill (part of); Station Avenue, Ponders End; Walsingham Road, London Road; Craddock Road, Southbury Road, The following streets have been dealt with under Section 150 of the Public Health Act, and properly metalled, channelled and paved, etc.:— Southfield, Nelson, Sutherland, Church and Aliens Roads, Ponders End; Salisbury, Ferndale, Ashton, Catherine, and Malvern Roads, Enfield Lock; Elmhurst Road, Enfield Wash; Halstead Road, Bush Hill Park. The roads at Forty Hill, Lavender Hill, Church Street and Chase Side, have been widened, thus effecting a much needed improvement. A new retaining wall has been built along the Turkey Street brook. 219 new houses have been certified as completed, and fit for human habitation. I also include with this the statistical report of the work done under the supervision of the chief Sanitary Inspector. Yours obediently, William Pennefather Warren, Medical Officer oj Health. THE URBAN DISTRICT COUNCIL OF ENFIELD. Special Report of the MEDICAL OFFICER OF HEALTH in reference to the Outbreak of DIPHTHERIA During 1908. Enfield : IAS. W. HATCH AND SON (T.U.) PRINTERS. Public Offices, En'field, January Hth, 1909. To the Chairman and Members of the Enfield, Urban District Council. Gentlemen, I beg to report to you as follows in regard to the outbreak of Diphtheria which took place in the district of Enfield in the latter part of the year just come to an end. It occurs to me that it would be well in the first instance to give a short resume of the Diphtheria history of Enfield for the last 21 years ; so that you may be in a better position to appreciate the conditions obtaining in Enfield prior to the outbreak. It will, no doubt, be well known to you that an epidemic of Diphtheria visited Enfield in the autumn of 1887, and ran from September to the following January, during which time 213 cases were reported, with 48 deaths; but from the fact that the Infectious Diseases Notification Act was not then in force it is not unreasonable to suppose that this number did not by any means represent the actual number of cases. Your late Medical Officer of Health (Dr. J. J. Ridge), was of opinion that this epidemic was mainly due to milk, and secondarily to school infection, and with this opinion Dr. BruceLow, the Local Government Board Inspector, agreed. In 1889. 6 deaths were certified as due to Diohtheria. The following table shows the number of Diphtheria cases reported, the number of deaths certified, and the population in each year since the Infectious Diseases Notification Act came into force on January 1st, 1890. Year. Population. No. of Cases. No. of Deaths. Year. Population. No. of Cases. No. of Deaths. 1890 25,000 52 4 1899 40,289 69 10 1891 31,532 41 6 1900 43,394 107 25 1892 33,570 94 19 1901 43,000 76 7 1893 34,295 128 16 1902 44,162 45 4 1894 37, 106 88 8 1903 49,151 47 6 1895 35,000 114 16 1904 49,699 53 1 1896 36,000 78 10 1905 51,315 39 2 1897 37,500 103 21 1906 52,797 56 6 1898 39,360 70 16 1907 54,688 83 15 1908 56,395 359 30 2 From this it would appear that Diphtheria has been for many years endemic in Enfield, with an occasional inclination to break out into a mild epidemic. To come now to 1908.—On referring to the Chart attached it will be seen that cases of Diphtheria varying from 1 to 8 were notified every week, dropping to 1 the third week in June. This was followed by one week without any; then the next, 2 cases were notified; then again there were 2 blank weeks ; then the next week two cases were reported, while the following week there were none ; following this the number increased until the highest point was reached in the third week in October, since when they have declined, until in the last week of the year they were reduced to nine. The total number of cases reported from July 28th to December 31st, was 298, and of these 212 were removed to Hospital and 86 isolated at home. Twenty of the cases proved fatal, 5 dying at home and 15 at the Hospital. Of the total deaths, 9 were males and 11 females. The total number of houses affected was 238,4 cases occurring in each of 4 houses, 3 in each of 9 houses, and 2 in each of 30 houses. LOCALITY. The total of 298 cases were distributed among the various wards as follows:— Chase. Town. Bush Hill Park. Ponders End. Ordnance. Total. Notifications 198 16 21 7 56 298 Deaths 12 1 4 0 3 20 Not only did the majority of the total number of cases occur in the Chase Ward, but they actually occurred in one very small part of it, viz. : a section bounded by Baker Street, Clay Hill, Lavender Hill, Holtwhites Hill and Parsonage Lane. The majority of Town Ward cases lived either in close proximity to the Chase Ward, or attended schools there, and might therefore be included with the Chase Ward cases. The next highest numbers will be found in the Ordnance Ward on the eastern side of the Parish. These occurred mostly round Ordnance Road and the New Estate. One of the Ponders End cases should really be included in the CHART SHEWING NUMBER OF CASES OF DIPHTHERIA NOTIFIED EACH WEEK DURING 1908. 3 Chase Ward return, as the family had only moved from Chase Side to Ponders End the same day as the case was notified. SCHOOLS. The histories of many Diphtheria epidemics show that prior to and during an outbreak many children suffer from ill-defined sore throats, and very readily contract the disease if exposed to infection, and this epidemic has proved no exception to the rule. Fortunately the School Authorities had appointed a School Medical Officer last Summer, and I am very pleased to be able to take advantage of this opportunity to testify to the very efficient service Dr. P. E. Gaffikin rendered during the outbreak. She constantly visited the various schools affected, examined the children, took ewabs from doubtful or suspicious cases, and was the means of detecting several "carrier cases" which under ordinary circumstances would most probably have escaped observation, and rendered the attack very much more severe. From the first both the increase and continuance in the number of cases notified gave me a good deal of anxiety, and every endeavour was made to cope with the outbreak. The cases as notified were closely enquired into, their isolation insisted upon, and as many as possible removed to the Isolation Hospital. Following the enquiries made in each case I soon realised that the question both of school attendance and milk supplies must be closely looked into. One of the first schools to claim my attention was Gordon Lane School (infants'). Six of the scholars having been notified between September 8th and 27th, the school was, on my recommendation, closed from September 28th to October 26th. On the 29th of Sepember, the day after the closing, three more scholars were notified s suffering from Diphtheria, but no more cases occurred among the hildren belonging to the school until three weeks after the re-opening, when one was reported on November 16th, one on November 29th, and one on December 11th, making a total of 12 cases amongst a total average attendance of 120. Advantage was taken of the opportunity afforded by the closing o have the school thoroughly disinfected and cleaned throughout. 4 The sanitary arrangements were at the same time overhauled, and several defects detected, which were immediately made good. St. Luke's Infants' School also became conspicuous at the same time, six cases occurring up to October 1st, the last one being a teacher. This school was closed from October 2nd to November 2nd. Two cases were reported after the closing, one on October 9th and one on the 27th; one of the two being a second case in an already infected house. When the school was re-opened on November 2nd one case was reported next day, one on the 6th, and one (the last) on December 14th, making a total of 11 cases out of an average attendance of 90. In addition to the foregoing schools, Chase Side Council Schools engaged our particular attention. This is a very large school consisting of three departments:—Boys', Girls', and Infants, the number of scholars on the books and the average attendance being as follows:— Boys' No. on Books 486 Girls' „ 495 Infants' „ 376 1,357 Average attendance 435. ,, 422. ,, 288. 1,145. Having regard to the large attendance at this school, and to the fact that Diphtheria had made its appearance among the children, I saw Dr. Gaffikin, the School Medical Officer, who very kindly promised to pay special attention to the scholars. Later on, hearing from her that there were a large number of children suffering from suspicious and doubtful-looking throats, and finding from an examination of swabs she sent me that a good many of these suspicious cases were really Diphtheria, and as by this time three of the boys, nine girls and twelve infants had been notified by various medical men, I recommended the closing of the school from October 10th to November 2nd, and this was done. During the time of the closing 8 boys, 13 girls and 2 infants; and from the re-opening to December 31st, 4 boys, 22 girls and 11 infants were notified, making a total for the whole period of the outbreak of 15 boys, 44 girls and 25 infants. Persistence in infection was particularly noticed in Standard 4b in the Girls' School, following the re-opening, 11 girls in that standard having been struck down by the disease in two months, and 5 as in spite of every precaution, including the exclusion of all contacts and children suffering from any slight indisposition, cases continued to occur, the Christmas holidays were, on my recommendation, anticipated, and this department closed on December l6th, since when only two cases have been reported, and they belonged to a different standard During the closure period, October 10th to November 2nd, the schools, together with the outbuildings and playgrounds, were thoroughly cleansed and disinfected. The sanitary arrangementswere also examined and found quite in order. When some cases began to appear again after the re-opening, the class-rooms implicated were sprayed each evening. The following is the number of cases whicu occurred in the other elementary schools in the same neighbourhood:— School. No. of Cases. Average Attendance. Number on Books. British Hall Mixed 6 114 144 St. Michael's Boys' 7 222 261 „ ,, Girls' 11 209 251 ,, ,, Infants' 14 168 209 St. Andrew's Girls' 1 175 198 „ ,, Infants' 2 120 149 St. John's, Clay Hill 6 61 85 Forty Hill 2 250 271 The conditions in these schools did not appear to me to be sufficiently serious to call for special treatment in the way of closing,, but very close attention was given both to cases and contacts, and where it appeared to be necessary disinfection of the schools was carried out. This report on the schools would not be complete without a reference to Chesterfield Road School in the Ordnance Ward, which is probably the largest school on the Eastern side of the parish, and it was among the scholars of this school that the majority of cases notified on that side occurred. The figures are:— 6 Department. No. of Cases. Average Attendance. Number on Books. Boys 9 404 426 Girls 12 422 466 Infants 9 468 540 Junior Mixed 5 368 402 Totals 35 1,662 1,834 From this it will be seen that the outbreak was not very serious here, but I may say that exactly the same precautions were taken as in the other schools. During the Christmas holidays the following schools have been disinfected throughout, and of course cleaned afterwards:— Chesterfield Road School All departments. Chase Side Council All departments. British Hall All rooms, &c. St. Michael's All departments. Gordon Lane All rooms, &c. St. Luke's Infants' do. In addition to the children attending school, 55 cases occurred among others under school age, while 35 adults were also attacked, 14 of them being males and 21 females. In this connection I would mention that a table is attached at the end of the Report giving a detailed account of the (a) Number of Cases, (b) Sex, (c) Age, and (d) Distribution in the District. This table bears out a well known point, viz.: that the female sex is generally a greater sufferer from Diphtheria than the male. In October when the elementary schools were closed, I communicated with the authorities controlling the following Sunday Schools on the Western side of the parish, suggesting to them the advisability of closing their schools at the same time, with the result that these schools were closed for three Sundays, October 18th and 25th, and November 1st, and I should like here to express my thanks to the Managers for their ready acquiescence to my suggestion. Christ Church Sunday Schools. Christ Church Hall. Primitive Methodist, Chase Side. 7 St. Michael's, Chase Side and Brigadier Hill. St. Andrew's, Cecil and Sydney Roads. Baker Street Mission. Gordon Lane (closing continued tor the three Sundays more.) St. Mary's, Windmill Hill. Cecil Hall. Baptist Church, London Road. St. John's, Clay Hill. Jesus Church, Forty Hill. Brigadier Hill Mission. Presbyterian Church. Shirley Hall. Latter Day Saints, Baker Street. Wesleyan, Chase Side. Baker Street Congregational. It has long been held that school influence plays a large part in the propagation of Diphtheria and other infectious diseases, and I think the experience of this epidemic further proves the correctness of this view; it has, however, been borne in on me strongly that school teachers, in their anxiety to preserve a good average attendance do not realise sufficiently the importance of early exclusion of children suffering from any indisposition, however slight, especially during the existence of an epidemic. MILK. It being recognised that milk has on many occasions played a very important part in connection with the spread of Diphtheria, cose attention was from the first given do the milk supply of the infected houses. It may be well here to mention the characteristics of a milk epidemic. A milk epidemic is characterised by the suddeness with which it makes its appearance, most of the cases being attacked at about the same time. The infected houses will for the most part be found to have been supplied by the same milk-vendor, and the sufferers are mostly women and children of the well-to-do classes. On making exhaustive inquiries into the milk supply of the affected houses it was found that no suspicion could be attached to any milkman supplying milk in the locality. Although there were 8 apparently a number of cases occurring on the rounds of three particular milk-vendors, inquiries showed that they probably supplied the largest amount of milk in Enfield, that the number of houses affected was a very small percentage, and that no cases occurred in the better class houses supplied by them, while personal visits both to their respective dairies and farms showed that they were quite alive to the necessity of absolute cleanliness in the milk business. The following table gives the details of the number of families in each ward supplied by the different milksellers, distinguished by a letter, and also those in which only condensed milk was used:— Purveyor. Chase. Town. Bush Hill Park Ponders. End. Ordnance Total Families. A 26 11 2 – – 39 B 23 1 — – — 24 C 23 — — — — 23 D 13 – – – — 13 E 14 – – – – 14 F 7 1 – – – 8 G 4 – – – — 4 H 3 – – – – 3 J 5 – – – – 5 K 2 — — – — 2 L 1 – – – — 1 M 1 – – – – 1 N 1 – – – – 1 0 1 – – – – 1 P – 1 – — — 1 Q – — 5 – — 5 R – – 5 – – 5 S – – 2 – – 2 T 1 – – – – 1 U – – 1 – – 1 V – – 2 – – 2 w – – – 2 – 2 X 5 – 1 2 – 8 Y – – – 1 — 1 Z – – – – 18 18 A' — — — — 3 3 B' — — — – 3 3 C' — – – – 4 4 D' – – – – 3 3 E' – – – – 3 3 F' 1 – – – – 1 G' 1 – – – – 1 H' 2 – – – – 2 J' 9 — 1 – 2 12 Condensed milk, of various brands 38 — 2 — 8 48 Totals 181 14 21 5 44 265 9 I think I may fairly claim that this table supports the view that this epidemic was not a milk one. The outbreak in the western division was mainly confined, as I have shown, to a small part of the Chase Ward, and altogether to houses of the artisan type; while the milk purveyors in question serve a much larger area and include in their round many well-to-do customers, who escaped entirely. I would also direct attention to the fact that 48 families used only condensed milk (of various brands). SANITARY CONDITIONS OF AFFECTED HOUSES. A careful inspection of the sanitary condition of the premises affected was at once instituted and is now nearly completed. While many defects were discovered which undoubtedly might have had a predisposing influence on the spread of the disease it soon became apparent that some cause in addition to sanitary defects and school infection must be looked for as the cause of the epidemic; and in this connection I would suggest:— Time of year, and Meteorological conditions. (1). Tine of Year. Diphtheria epidemics mostly commence about August and September, gain their height in October and November, and then gradually die down. (2). Meteorological Conditions. The meteorological conditions of this past summer have been rather abnormal, the characteristics were little sunshine aud frequent rain. In July and August there was continual rain with a high temperature, but not sufficient sun to dry and purify the soil, and then to make matters worse we had early in September a heavy downpour. This being followed by a prolonged spell of warm, humid weather both by day and night, presented conditions most favourable for the growth, of any latent germ life. As I have already mentioned incidentally, many cases of nonspecific sore throat occurred amongst children in the earlier part of 10 the epidemic, and it would appear to be not at all improbable that these sore throats were primarily due to the climatic conditions just mentioned; and the disease once started, its rapid progress would be accounted for by personal contact. While on this point I think it is worth mentioning that it was during this warm weather that the outbreak assumed its most serious aspect, and that as colder weather set in the notifications dropped considerably. There was also a noticeable reduction in the disease since the 14th of December when we had a heavy fall of rain, and a thunderstorm; while since the snowfall and hard frost that followed near the end of the month, the disease has almost disappeared, a case occurring only now and then. ENFIELD LOCK. While the outbreak proper was taking place in Enfield, a smaller outbreak was going on in the neighbourhood of Enfield Lock, 56 cases having been notified from July to December, but I have not been able to trace any connection between the two. Diphtheria has been rather prevalent on the eastern side during the early part of the year, 35 cases having been reported up to the end of July, and I am inclined to think that the 56 cases in the autumn were a recrudescence of the disease. 35 of the cases have already been referred to in my remarks on Chesterfield Road School, and it is interesting to note that 25 of the cases occurred in 10 houses. MEASURES TAKEN TO COPE WITH THE DISEASE. In addition to those measures already mentioned, every endeavour was made to ensure proper isolation of those cases not removed to hospital, also of contacts and doubtful cases, and quite early in the epidemic I sent a circular letter to every member of the Medical profession practising in the neighbourhood, drawing their attention to the fact that an outbreak of Diphtheria had arisen, and requesting them to secure as far as possible the isolation of any cases of sore throat that might come under their notice. Inspection of premises and full inquiries were made in each case, and close attention was also given to secure the speedy abatement of all nuisances found; houses, drains, bedding and clothes were disinfected; disinfectants were freely supplied; and anti-toxin was issued free to medical men; while the Council also arranged with me to make a bacteriological examination of any swabs sent for that purpose. I have received 306 swabs, 128 of which, on examination, were found to be positive, and the remaining 178 negative. The Hospital accommodation was severely taxed on several occasions, but in each case arrangements were speedily made by the Joint Board, in conjunction with the Hospital staff, which removed the tension, and enabled us to get all cases requiring removal away. I should like to express my thanks to Mr. John McEwan, "Carisbrooke," Bycullah Park, for the very great help he gave in allowing me to have access to his meteorological records. Further, I should be greatly wanting in a sense of both duty and gratitude if I did not freely acknowledge the invaluable and ever ready assistance I have received at all times from your Sanitary Inspector, Mr. Munro; he has always put himself at my service, and most ungrudgingly and cheerfully given me the benefit of his long experience in the District. It will necessarily be clearly realised that this outbreak has entailed a large amount of extra labour on the Sanitary Department, but I am glad to say that, owing to the industry and zeal of the individual members of the staff the extra work has been adequately dealt with, and I feel the Council is to be congratulated on the very able sanitary staff it possesses, both indoor and outside. W. P. WARREN, Medical Officer of Health. Table referred to on Page 6. Particulars re Ages and Sexes of Cases of Diphtheria notified from July 25th to December 31st, 1908. Ages Chase Side, Ac. Town. Bush Hill Park. Ponders End. Enfleld Lock and Highway. Outlying Districts. Totals of each Sex. Totals M. F. M. F. M. F. M. F. M. F. M. F. M. F. Under 1 ... 1 ... ... ... ... ... ... 1 ... ... .. 1 1 2 1-2 2 1 ... ... ... ... ... ... ... ... ... ... 2 1 3 2-3 8 4 ... ... 1 1 1 ... 2 ... ... ... 12 5 17 3-4 4 6 ... ... l 2 1 ... 3 1 ... 1 10 10 20 4-5 9 8 ... ... l 1 ... ... 2 3 ... 1 12 14 26 5-6 12 17 ... ... 1 1 ... ... 3 2 1 3 17 23 40 6-7 5 5 ... 1 l ... ... 2 3 2 ... ... 9 10 19 7-8 7 13 ... ... 1 ... ... ... 3 3 1 1 12 18 30 8-9 3 11 ... ... 1 ... ... ... 3 ... l 1 8 12 20 9-10 6 8 ... 1 1 ... ... ... 3 3 ... 2 10 14 24 10-11 4 13 ... 1 ... ... ... ... 1 3 1 ... 6 17 23 11-12 2 6 ... ... ... ... ... ... 1 2 ... 1 3 9 12 12-13 3 5 ... ... ... ... ... ... 1 1 ... ... 4 7 11 13-14 2 ... ... 1 ... ... ... ... 2 1 ... 1 4 3 7 14-15 4 1 ... ... ... ... ... ... ... ... ... ... ... 1 5 15-16 ... 1 ... 1 ... ... ... ... ... ... ... ... 1 2 3 16-17 2 1 ... ... 1 ... ... ... ... 1 ... ... 4 2 6 17-18 ... ... ... ... ... ... ... ... ... 2 ... ... ... 2 2 18-19 1 ... ... ... ... ... ... ... ... 1 ... ... 1 1 2 19-20 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 20-21 ... 2 ... ... 1 ... ... ... ... 1 ... ... ... 3 5 21-22 ... ... ... ... 1 ... ... ... ... ... ... ... 1 ... 1 22-23 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 23-24 ... ... ... 1 ... ... ... ... ... ... ... ... ... 1 1 24-25 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 25-26 ... ... ... 2 ... ... ... ... ... ... ... ... ... 2 2 26-27 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 27-28 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 28-29 ... 1 ... ... ... ... ... ... ... ... ... 1 ... 2 2 29-30 1 ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 30-31 ... 1 ... ... ... ... ... ... ... ... ... ... 1 1 2 31-32 ... ... ... 1 ... ... ... ... ... ... ... ... ... 1 1 32-33 ...... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 33-34 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 34-35 ... 2 ... ... ... ... ... ... ... ... ... ... ... 2 2 35-36 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 36-37 ... ... ... ... ... ... ... ... ... ... ... 1 ... 1 1 37-38 ... 1 ... ... ... ... ... ... ... ... ... ... ... ... 1 38 39 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 39-40 ... ... ... ... ... ... ... ... ... ... 1 1 1 1 2 40-41 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 41-42 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 42 43 ... 1 ... ... ... ... ... ... ... ... ... ... 1 1 2 43-44 ... ... ... ... ... ... ... ... ... ... ... 1 ... l 1 44-45 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 45-46 ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 46-47 ... ... ... 1 ... ... ... ... ... ... ... ... ... l 1 76 109 1 10 12 7 3 3 31 26 5 15 128 170 298 17 Public Offices, Enfield, Feb., 1909. Report of the Inspector of Nuisances for year 1908. To the Chairman and Members of the Urban District Council of Enfield. Gentlemen, I beg to submit my Report as follows, for the year ending December 31st, 1908, giving particulars of the work done under my supervision in connection with your Sanitary Department. Inspections:— Houses inspected from house to house 828 Houses inspected in connection with Infectious Disease 547 Other houses and premises inspected 689 Factories inspected 46 136 workshops and workplaces, including 12 laundries 335 Outworkers 32 44 bakehouses in the district, of which 42 are in use 199 17 slaughter-houses, inspected frequently. Total number of visits 280 Carried forward 2,956 18 Brought forward 2,956 37 cowsheds inspected frequently. Total number of visits 184 74 dairies and milkshops inspected frequently. Total number of visits 517 28 schools, inspected frequently. Total number of visits 149 81 shops where ice cream made. Total number of visits 162 Public house urinals inspected 101 Fish shops 73 Employment of Children Act (inspections re) 192 1,378 4,334 Other inspections, including works in progress, also visits in connection with cases of infectious disease, etc. 10,030 Smoke observations 56 14,420 Notices issued For repairs to drains, and abatement of nuisances 169 Under Infectious Diseases Act— To occupiers 387 To schools 3890 4,446 19 Letters sent:— In lieu of notices 1421 Other letters 1222 2,643 Houses and parts of houses cleansed, repaired, etc. 232 Roofs repaired 98 Gutters and downpipes repaired 129 Cesspools emptied 154 House drains cleared, repaired, etc. 267 House drains tested, examined, etc. 439 House drains reconstructed 58 Soil-pipes and drains ventilated, including repairs to ventilators 76 Closets provided with proper flushing cisterns or water supply 186 New closets provided 7 Closets repaired, cleansed, etc. 203 Storage cisterns repaired, covered cleansed, etc. 54 Water laid on or restored 20 Samples of water taken 8 New storage cisterns provided 13 Wells cleansed 1 Yards paved, or existing paving made good 157 Dustbins repaired or new ones provided 197 Manure heaps removed 70 Fowls and other animals removed 42 20 Other nuisances abated 89 Ditches cleaned out 9 Cases of overcrowding abated 37 Houses fumigated after infectious disease 512 Houses fumigated after phthisis 13 525 Rooms stripped and re-papered, etc., after occupation by cases of infectious disease 136 Articles of clothing and bedding, etc., disinfected after infectious disease 5782 Articles of clothing and bedding, etc., destroyed 47 5,829 Articles of clothing and bedding, etc., disinfected after Phthisis 100 Articles of clothing and bedding, etc., destroyed after Phthisis 2 102 Articles of clothing and bedding, etc., disinfected after cancer 8 Library books disinfected 102 Cases of Scarlet Fever removed to hospital 172 Cases of Diphtheria removed to hospital 270 Cases of Enteric Fever removed to hospital 0 442 21 Gipsy vans removed, from district 42 Ventilation provided under ground floors, and causes of dampness removed 63 Articles or parcels of unsound food destroyed 19 Removal of House Refuse. The removal of house refuse, which is carried out by the Council's own staff, has received close attention, 5,522 loads having been collected and taken to the Council's shoots or disposed of to brickmakers. Factory and Workshops Acts, 1901 and 1907. A register of all workshops is kept, and at the end of 1908 there were 128 workshops, 12 laundries and 44 bakehouses (including 1 underground bakehouse), registered. These have all been inspected several times in the year, and the following contraventions were found requiring action, which was taken:— W.C.'s with defective flushing put in order 13 Workshops and bakehouses cleansed and limewashed 28 Overcrowding abated 2 Other nuisances abated 9 22 Homework. Nine lists have been received giving addresses of outworkers, also nineteen addresses of outworkers from other districts. Ten addresses of outworkers have been forwarded to other districts. An inspection was made of the residences of all outworkers living in this district. Milk. Very frequent inspections have been made of the dairies and milkshops in the district, in order to see that the requirements of the Dairies, Cowsheds and Milkshops Order, and the Regulations in force in the district are complied with. Ice Cream. 81 shops where ice-cream was made or sold were inspected during the summer, 162 visits being made to them, and where necessary instructions given in regard to the cleansing of utensils and premises. Unsound Food. A regular inspection has been made of meat slaughtered and offered for sale in the district, including the stalls in the markets each week. 19 parcels of organs were found to be affected with disease. These were surrendered by the owners and destroyed. 23 The following articles were also submitted for inspection, and as in each case it was found that they were unfit for the food of man, certificates to that effect were given, so that the owners could secure the return of the money paid, from the wholesale traders:— January 22nd 1 case of fresh herrings. „ 29th 1 do. February 11th 1 case of fish. June 1st A basket of shrimps. August 27th 1 box of kippers. ,, ,, 2 sieves of damsons. September 22nd 1 cask of fresh herrings. October 5th 1 sack of winkles. November 17th 1 trunk of small plaice. House Drainage. As will be seen from the report, a large number of house drains have been tested during the past year and defects found have been rectified. In all cases where possible the work was tested with water during progress, and a final test with smoke and water applied on completion. 24 Public Elementary Schools. By an arrangement between the Council and the Education Committee, I have all the sanitary arrangements attached to the non-provided schools regularly cleansed and flushed each day, while we also make periodical inspections of the sanitary conveniences at the Provided Schools, and report as to their condition to the Education Committee. Owing to the severe outbreak of Diphtheria which took place at the latter part of the year, your staff were kept so fully occupied dealing with these cases that the ordinary inspections of dwellings and registered premises could not be so closely followed up, but every endeavour was made to prevent the work falling into arrear. The Staff of the Sanitary Department now consists, in addition to myself, of the following Officers:— Mr. Fred Wilson, 1st Assistant. Mr. T. M. Boswell, 2nd Assistant. Mr. Noel Smith, 1st Clerk. Mr. S. Coulter, 2nd Clerk. I should like to take this opportunity to acknowledge and thank them for the ready help which they have always given me, and the interest displayed in their work. I also include 25 in this acknowledgment Mr. J. Ellis and theother members of the out-door staff connected with this Department. I am, Gentlemen, Your obedient servant, A. J. MUNRO, M. R. San. I., Inspector of Nuisances.