ENF 4 THE Urban District Council of Enfield. ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH, FOR 1909, TOGETHER WITH THE ANNUAL REPORT OF THE INSPECTOR OF NUISANCES. PUBLIC OFFICES, ENFIELD, February 23rd, 1910 Medical Officer of Health's ANNUAL REPORT for 1909. To the Urban District Council of Enfield. Gentlemen, I have the honour to submit to you my Annual Report for the year 1909, with which is incorporated the Report of your Sanitary Inspector Mr. A. J. Munro, giving particulars of the work done in the Sanitary Department. In accordance with the Memorandum of the Local Government Board as to the Annual Reports of Medical Officers of Health, I propose in the first instance to give some particulars of the physical features and general character of the District, and condition of its population. Enfield, one of the largest parishes in England, containing 12,600 acres, naturally divides itself into three parts; The Western, mainly agricultural, with centres of population at Hadley Wood 4 and Cock fosters, is situate on the London clay and is hilly in character. The Central includes the Ridgeway, old Town, Bush Hill Park, Clay Hill and Forty Hill, part of which is, like the Western, on the London clay, and the remainder soil of a loamy nature with gravel below. There is a considerable population in the neighbourhood of the Town, partly of a residential and business, also industrial nature. Bush Hill Park is now almost entirely built upon, the inhabitants of which are mostly industrial. The Eastern lies in the Lea Valley. The soil is of loam lying on a deep substratum of gravel. There are two principal centres of population, viz., Ponders End and Enfield Lock, and the inhabitants are mainly employed in the local factories, horticulture and market gardening. In addition to the Royal Small Arms Factory at Enfield Lock, there are the Corticene Works, Edison and Swan United Electric Light Company's Works, Enfield Gas Works, and the Metallic Tube Works at Ponders End, also The Imperial Lamp Works, North Metropolitan Electric Power Station and White Lead Works, at Brimsdown, Eufield Highway. In addition to these there are many smaller works and steam laundries in the District, while there is also in course of construction works at Brimsdown for the manufacture of Ruberoid. Population. The population of Enfield at the census of 1901 was 42,738, and the estimated population at the middle of 1909 was 57,453. This is calculated on the basis of allowing 5.37 persons to the 10,739 inhabited houses. 5 Enfield is divided into six Wards as follows:— Ward Inhabited Houses Uninhabited Houses Total Town & Cock fosters Wards 1451 116 1567 Chase 2312 260 2572 Ordnance 2063 143 2206 Green St. & Ponders End 2593 123 2716 Bush Hill Park 2320 128 2448 10739 770 11509 showing an increase on the previous year of 237 inhabited houses, and a decrease of 3 uninhabited ones. The housing accommodation, especially for the working class, appears to me, in view of these figures and from personal knowledge, to be quite adequate for the needs of the population of the District. There are no back-to-back houses in the District, and the air-space about dwellings is generally sufficient, although I regret to say the cleanliness of the surroundings in many cases due to the inaction or neglect of tenants leaves much to be desired, though it is hoped that by constant supervision this will eventually be remedied. Plans of all new houses and alterations have to be submitted for the approval of the District Council, and the erection of dwellings and other buildings is closely supervised by the Council's Surveyor and Building Inspectors. The Byelaws require that no house is to be occupied until the drainage has been completed, and the dwelling certified as in every respect fit for human habitation. 6 No special action has been taken during the past year under the Housing of the Working Classes Act, but its requirements have not been lost sight of, and I have given close attention to the condition of dwellings in various parts of the District, while, as will be seen from the particulars furnished by the Sanitary Inspector, much work has been done in the way of repairing and improving the houses. VITAL STATISTICS. Births. The number of births registered was:— Boys Girls Total 704 696 1400 including 40 illegitimate births, 14 male and 26 females. This gives a birth-rate of 24.36 per thousand of the population, which I regret to say, shows a serious diminution on previous years, as the following figures show:—1905, 26.44; 1906, 25.45; 1907, 26.18, and 1908, 25.18. The birth-rate for England and Wales for the year is 25.6. Deaths. 617 deaths were registered in the district during the year, 319 of these being males and 298 females, giving a crude death-rate of 10.73. To these must be added 77 deaths of residents of Enfield registered outside the district, and 26 deaths of non-residents occurring in the district should be subtracted; giving a total of 668 deaths. This gives a recorded death-rate of 11.62; and a death-rate corrected for age and sex distribution of 12.22 per 1000, as against 14.5 (the lowest on record) for England and Wales for the same period. 7 The corresponding figures for the last three years were. 1906 1907 1908 Recorded death-rate 11.2 11.68 11.18 Corrected ,, 11.7 12.9 11.76 Classifying the 668 deaths above mentioned, according to their sex and age, gives the following table:— Male Female Total Under 1 year 87 69 156 1 to 5 years 53 30 83 5 to 10 years 8 9 17 10 to 15 years 10 8 18 15 to 20 years 7 9 16 20 to 25 years 7 6 13 25 to 35 years 21 18 39 35 to 45 years 29 21 50 45 to 55 years 27 21 48 55 to 65 years 41 32 73 65 to 75 years 40 46 86 75 to 85 years 17 31 48 Over 85 years 7 14 21 354 314 668 It is interesting to note that 40 deaths registered were of persons over 80 years of age, 13 being males and 27 females, whose ages ranged 8 from 80 to 99 years, one woman dying at 94 and a man dying at 99 years. There were 20 deaths from violence, 12 being by accident (including an infant suffocated by overlaying); one murder; seven suicides (three by poisoning, two by drowning, and two by being run over by railway trains). Infantile Mortality. The total number of deaths occurring among infants under one year old was 156, giving a death-rate of 111.42 per 1000 births. The corresponding figures for the last three years were:— 1906, 105.7; 1907, 116.6, and 1908, 90.14. The chief causes of death during the year under review were:—Premature birth (28), debility (24), bronchitis (18), diarrhoea (17), pneumonia (12), and convulsions (12). The deaths for the last 10 years will be found in Table 1. Table 2 gives the vital statistics for the district for 1909 and the previous 10 years. Table 3 shows the cases of infectious disease notified during the year. Table 4 gives the various causes of death at all ages, and Table 5 those under one year. TABLE I. Vital Statistics of Whole District during 1909 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. Rate per 1000 Births registered. Number. Rate. Number. Rate.* 1 2 3 4 5 6 7 8 9 10 11 12 13 1899 40,289 1,155 28.6 203 1750 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 30.6 174 127.1 608 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 28.7 226 158.0 641 12.8 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 26.1 167 116.0 614 11.4 24 9 62 639 11.68 1908 56,185 1,420 25.18 134 90.1 621 11.05 131 60 64 625 11.18 Average for years 1899. 1908 48,466 1,321 27.25 164 124.29 589 12.16 – – – – – 1909 57,453 1,400 24.36 156 104.28 617 10.73 96 26 77 668 11.62 *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. TABLE II. Vital Statistics of Separate Localities in 1909 and previous years. Year. Population estimated to middle of each year. Births registered. Deaths at all ages. Deaths under 1 year 1899 40,289 1,155 613 203 1900 43,394 1,186 605 172 1901 4 3,000 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 1,334 594 148 1907 54,688 1,432 639 167 1908 56,185 1,420 625 134 Averages of Years 1899 to 1908 48,466 1,321 593 164 1909 57,453 1,400 668 156 TABLE III. Cases of Infectious Disease notified during the Year 1909. Notifiable Disease. Cases Notified in Whole District. At all Ages At Ages—Years. Under 1. 1 to 5. 5 to 15. 15 to 25. 26 to 65. 65 and upwards. Total cases removed to Hospital. Small-pox 0 – – – – – – – Cholera 0 – – – – – – – Diphtheria (including Membranous Croup) 223 4 49 148 12 10 – 185 Erysipelas 31 1 1 1 4 19 5 – Scarlet Fever 283 1 61 176 27 18 – 248 Typhus Fever 0 – – – – – – – Enteric Fever 2 – – – – 2 – 1 Relapsing Fever 0 – – – – – – – Continued Fever 0 – – – – –– – – Puerperal Fever 4 – – – – 4 – 0 Plague 0 – – – – – – – Consumption Notified under Public Health (Tuberculosis) Regulations, 1908 11 – – 1 1 9 – – Notified under arrangement for voluntary notification 34 – – – 7 27 – – Totals 588 6 111 326 51 89 5 436 TABLE IV. Causes of, and Ages at, Death during Year 1909. 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 nuder 15. 15 and under 25. 25 and under 65. 65 and upwards. Small-pox ... ... ... ... ... ... ... ... Measles 33 7 25 1 ... ... ... 1 Scarlet Fever 6 ... 3 3 ... ... ... 9 Whooping-cough Diphtheria (including 9 4 5 ... ... ... ... ... Membranous Croup) 19 1 7 9 1 1 ... 26 Croup 2 1 1 ... ... ... ... ... Fever Typhus ... ... ... ... ... ... ... ... Enteric ... ... ... ... ... ... ... 6 Other continued ... ... ... ... ... ... ... ... Epidemic Influenza 5 ... ... 1 ... 2 2 ... Cholera ... ... ... ... ... ... ... ... Plague ... ... ... ... ... ... ... ... Diarrhœa 19 17 2 ... ... ... ... ... Enteritis 5 5 ... ... ... ... ... ... Gastritis ... ... ... ... ... ... ... ... Puerperal Fever 1 ... ... ... ... 1 ... ... Erysipelas ... ... ... ... ... ... ... ... Phthisis 36 ... 1 3 5 26 1 3 Other tuberculous diseases 26 5 7 7 1 6 ... 1 Cancer, malignant disease 31 ... ... ... 1 16 14 7 Bronchitis 52 18 11 ... ... 7 16 1 Pneumonia 59 12 11 ... 3 20 13 3 Pleurisy 4 ... l ... ... 3 ... ... Other diseases of Respiratory organs 10 ... l 1 1 4 3 1 Alcoholism 7 ... ... ... ... 6 1 ... Cirrhosis of Liver Venereal Diseases ... ... ... ... ... ... ... ... Premature Birth 28 28 ... ... ... ... ... ... Diseases and Accidents of Parturition 9 4 ... ... ... 5 ... ... Heart Diseases 78 3 l 4 4 39 27 8 Accidents 12 1 ... 1 3 5 2 2 Suicides 7 ... ... ... ... 7 ... 1 Nephritis 9 ... ... ... ... 8 1 4 Apoplexy 20 ... ... ... ... 6 14 6 Diabetes 6 ... ... ... 1 3 2 1 Old Age 37 ... ... ... ... 1 36 9 Murder 1 ... ... ... 1 ... ... ... All other causes 137 50 7 6 8 41 25 7 All Causes 668 156 83 36 29 207 157 96 TABLE V. Infantile Mortality during the Year 1909. 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. 2 3 Months. 3-4 Months. 4-5 Months. 5-6 Months. 6-7 Months. 7-8 Months. 8-9 Months. 9-10 Months. 10-11 Months. 11-12 Months. Total Deaths under One Year. All Causes Certified 35 12 6 5 58 15 8 11 8 7 11 7 6 8 8 9 156 Uncertified ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... i. Common Infectious Diseases Small-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Chicken-pox ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Measles ... ... ... ... ... ... ... ... ... ... 1 2 2 1 ... 1 7 Scarlet Fever ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Diphtheria (including Membranous Croup ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... 1 1 Whooping Cough ... ... ... ... ... ... ... ... 1 1 ... ... 1 1 ... 4 ii. Diarrhœal Diseases. ... ... ... 1 1 1 3 3 1 1 2 ... ... 2 2 1 17 Enteritis, Muco-enteritis ... ... ... ... ... ... ... 2 1 ... 1 ... ... ... 1 ... 5 Gastro enteritis Gastritis, Gastro ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... intestinal Catarrh iii. Wasting Diseases. Premature Birth 22 2 2 1 27 1 ... ... ... ... ... ... ... ... ... ... 28 Congenital defect 2 ... ... ... 2 1 ... ... ... ... ... ... ... 1 ... ... 4 Injury at birth 2 ... ... ... 2 ... ... ... ... ... ... ... ... ... ... ... 2 Want of Breast-milk, Starvation ... ... ... 1 1 2 ... ... ... ... ... ... ... ... ... ... 3 Atrophy, Debility Marasmus 3 5 1 ... 9 5 2 1 2 1 1 ... ... ... 1 2 24 iv.Tuberculous Diseases Tuberculous Meningitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Tuberculous Peritonitis: Tabes Mesenterica ... ... ... ... ... ... 1 2 ... ... ... ... ... ... ... ... 3 Other Tuberculous Diseases ... ... ... ... ... ... ... ... ... ... ... ... ... 2 ... ... 2 v. Other Causes. Erysipelas ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Syphilis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Rickets ... ... ... ... ... ... ... ... ... ... 1 ... ... ... ... ... 1 Meningitis(not Tuberculous) ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Convulsions 1 1 2 ... 4 1 1 2 1 ... 1 1 ... ... ... 1 12 Bronchitis ... 1 ... ... 1 2 1 ... 2 2 2 2 1 2 1 2 18 Laryngitis ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... Pneumonia ... 1 1 ... 2 ... ... 1 ... 1 2 2 2 ... 1 1 12 Suffocation, overlying 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 Other Causes 4 2 ... 2 8 2 ... ... ... 1 ... ... ... ... 1 ... 12 35 12 6 5 58 15 8 11 8 7 11 7 6 8 8 9 156 Population, estimated to middle of 1909, 57,453. Births in the year legitimate, 1,360. illegitimate, 40. Deaths in the year of legitimate infants illegitimate infants 156. Deaths from all Causes at all Ages, 668. 14 Zymotic Diseases. The following table shows the deaths registered in the district from the seven chief zymotic diseases during the past five years. The figures for Scarlet Fever, Diphtheria, and Enteric Fever include the deaths that occurred at the Joint Board's Isolation Hospital, where patients belonging 10 other districts are visited. Those for Enfield alone being as stated in the next table following, viz., Scarlet Fever G, Diphtheria 19, and Enteric 0. 1905 1906 1907 1908 1909 Small Pox 0 0 0 0 0 Scarlatina 4 7 15 16 9 Diphtheria 2 6 15 53 26 Measles 12 11 10 6 33 Enteric Fever 0 3 1 2 6 Whooping Cough 15 7 12 3 9 Epidemic Enteritis 36 66 20 4 19 69 100 73 84 112 The zymotic death-rate, after deducting 16 deaths of persons from outside this district who died in the Isolation Hospital is 1.48 per 1000 for 1909, the increase on the previous year (.88) being explained in the following table:— Deaths. Death rate. Scarlatina 6 .10 Diphtheria 19 .33 Enteric Fever 0 0.00 Measles 33 .57 Whooping Cough 9 .15 Epidemic Enteritis 19 .33 86 1.48 15 Notification of Infectious Disease. The cases of infectious disease reported each quarter were as follows:— 1st Qtr. 2nd Qtr. 3rd Qtr. 4th Qtr. Total. Total number of cases per 1000 population Scarlatina 76 57 72 78 283 4.92 Diphtheria 115 40 34 33 222 3.86 Membranons Croup 0 1 0 0 1 .01 Enteric Fever 2 0 0 0 2 .03 Small Pox 0 0 0 0 0 .00 Erysipelas 13 6 5 7 31 .53 Pnerpural Fever 2 1 1 0 4 .06 208 105 112 118 543 9.61 The following table gives the number of cases of each infectious disease notified during the past five years:— 1905 1906 1907 1908 1909 Scarlatina 194 259 353 202 283 Diphtheria 39 56 83 369 222 Membranous Croup 0 2 1 2 1 Enteric Fever 9 24 10 5 2 Small Pox 1 0 0 0 0 Erysipelas 31 45 30 36 31 Puerpural Fever 1 2 1 3 4 275 388 478 617 543 16 Scarlet Fever. Scarlet fever, I regret, has been more prevalent during 1909 than in the previous year, 283 cases being notified as against 202 in 1908, in spite of the removal of the majority of the patients to the Isolation Hospital, and strict quarantine for a sufficient time on their return. Fortunately, however, the disease has been generally of a mild type, as the number of deaths— only six—shows. DIPHTHERIA. The number of cases of this disease notified during the year was unfortunately large, but when it is explained that during the first quarter when infection would doubtless be remaining from the outbreak of the previous year, the larger proportion, viz., 115, were reported, and that this number exceeds the three other quarters together, which were respectively 40, 34 and 33, making a total for these three quarters of 107, or for the year 222, it will be seen that there was a very great improvement during the latter part of the year, as a glance at the accompanying chart will show. It may be of interest to mention that Enfield was not the only district in the county suffering from this disease, for it seems to have been generally prevalent in several other districts lying to the North of London. There can be little doubt that the metereological conditions obtaining during the greater part of last year, viz., a very large number of rainy days causing continual dampness with a corresponding want of sunshine were extremely Urban District Council of Enfield. Chart Shewing Number of Cases of Infectious Diseases Notified During Each Week of the Year 1909. 17 favourable to the development of microbes in general, among which the Diphtheria Bacillus must be included. Locality. The total of the 222 cases were distributed among the various words as follows:— Town. Chase. Bush Hill Park. Street Green. Ordnance. Hadley & Cockfosters. Notifications 18 115 26 10 50 3 Deaths 1 8 3 3 4 0 It will be of interest here to mention that the larger number of cases reported in the Chase and Ordnance Wards, as will be seen from the table included (see page 22), occurred in the first two months of the year or thereabouts, and that for the last three months these portions of the district have been practically free from this disease, only four cases being reported in each of the wards for this time. The number for which Bush Hill Park Ward is responsible were due to an outbreak occurring in the latter part of October in connection with St. Andrew's Infants' School, to which I make further reference later on. Schools. While it is evident that the number of cases occurring in the Chase Ward would entail a corresponding increase in cases at the Chase Side Schools, at which the majority of the children attend, it fortunately did not become so serious as to necessitate the closing of the school, and 18 this I think is mainly owing to the very active part taken by the School Medical Officer, who on repeated occasions specially visited the schools, and excluded all suspicious cases, while I also visited other absentees, where a medical man was not in attendance. This outbreak rapidly subsided, and there was no cause for any special anxiety in connection with the schools until the latter end of October, when several cases were reported among children attending St. Andrew's Infants' School, and living in Bush Hill Park, and as on visiting many absentees and taking swabs of suspicious cases and contacts I found in five days no less than seven children harbouring Diphtheria Baccilli, although showing no clinical symptoms, and swabs sent by the School Medical Officer and other medical men showed positive results in some cases, I advised, after consulting with the School Medical Officer, that the school be closed for a fortnight, which was done by an order of the District Council. Following our regular practice the school premises were thoroughly disinfected and cleansed during the period of closure, and the sanitary arrangements overhauled. The school was re-opened on November 15th, and it has since remained free from disease. This little outbreak necessitated a large number of visits to contacts, etc., both on the part of myself and the Sanitary Staff, and as showing some of the difficulties I had to contend with, on October 27th from information received on visiting a house where a case had been notified, I made a call at a house in another street, there discovering a boy who had been ill for some three 19 weeks without medical attention, and whose throat and nose proved to be in an active state of Diphtherial infection. This boy was isolated and swabbed at intervals, and continued infective right away until the middle of December. All the [schools implicated were thoroughly disinfected as occasion arose. Milk Supply. A very close watch was kept on the various milk supplies throughout the year, but in no case could I trace any connection between the cases of Diphtheria and milk supply. Sanitary Condition of Affected Houses. A careful inspection was as usual made of every house affected, and while defects were frequently found in the sanitary arrangements, they were in many cases only of a minor character, and such as one must expect to find in the wear and tear of cottage property. I received 757 swabs of suspected cases for bacteriological examination from 23 medical practitioners in the District. Of these swabs 149 were positive and 608 negative, showing a percentage of 18.3 positive swabs. I think that the following extract from a Memorandum on Closure of and Exclusion from Schools, issued by the Local Government Board and Board of Education, the recommendations in which have been adopted by the Council, is sufficiently interesting to warrant quotation in full:— 20 Diphtheria. A. Advantage of Bacteriological Examination. "42. The examination of the throats of 'contacts,' "whenever practicable, by bacteriological means, is a most "important aid to precautionary measures against the "spread of diphtheria. If a positive result is obtained in "the case of children showing no evidence of diphtheria, "the presence of some measure of infection must be "assumed, though it will not be advisable to insist on the "removal of such patients to an isolation hospital. "it is recognized that in many sanitary districts "arrangements do not exist for such examinations; but "it has been thought better to set forth the line of action "commonly adopted in the best organised sanitary districts. "Clinical examination of contacts and other children often "throws valuable light on the origin of outbreaks of "diphtheria. Particular attention should be paid to child"ren who have been absent without known cause, or who "show evidence of pallor, enlarged glands, or sore noses." B. Rules for Exclusion of Individuals. (1) As regards each child attacked by the disease. "43. (a) When treated in the Isolation Hospital the "patient should, when practicable, be detained until three "successive swabs taken on different days have given con"sistent negative results. These swabs should not be "taken until at least 48 hours have elapsed since the last "application of any disinfectant to the throat. "In view of the debility left by an attack of diphthe"ria, and the possible return of infectivity in the secretions "of the nose or throat a notice should be sent to the "teacher stating that the child should not return to school "for four weeks after return home.* "(b) When the patient has been treated at home three "successive negative swabs should, when practicable, be "obtained as above; and after disinfection of the patient "and his rooms and belongings, the same period of subse"quent abstention from school attendance as above should "be enjoined." (2). As regards children living in infected houses. "44 (a) When the patient has been removed to the 21 "Isolation Hospital the teacher and parent should be "instructed to keep all children living in the same house "away from school during the next two complete weeks, "or even longer, unless these children have been cleared "by negative result of bacteriological examination. "This interval is desirable owing to the frequent "occurrence of slight cases of diphtheria and "carrier" "cases. "(b) When the patient is treated at home no other "child from the same house should attend school while ''the patient is infectious nor for four weeks afterwards."* Enteric Fever. It is especially gratifying, in view of the following extract from a lecture by Dr. Thorne Thorne, the late Chief Medical Officer of the Local Government Board, to note that only two cases of Enteric Fever were notified in the district during the year, as compared with five and ten in previous years.:— "Enteric Fever has always been regarded as standing foremost in this country among those diseases which were classed by Sir John Simon as forming the specified filth-infections, and it has also been recognised as typical of that class of disease which is most amenable to such preventive action as is involved in the construction of proper works of sewerage and drainage, and in the adoption of adequate systems of refuse disposal, and which tends to free the air and soil from filth." I received one specimen of blood from a suspected case of Enteric Fever which by the Widal test proved negative. * Sometimes this period may be reduced to two weeks. 22 TABLE REFERRED TO ON PAGE 17. Wards in which cases of Diphtheria occurred during 1909. Week ending. Town Ward. Chase Ward. Bush Hill Park Ward. Green Street and Ponders End Ward. Ordnance Ward. Hadley and Cockfosters Ward. Totals. Jan. 7 ... 3 ... ... ... ... 3 14 ... 1 1 ... ... ... 2 21 ... 5 ... ... 6 ... 11 28 ... 1 2 ... 7 ... 10 Feb. 4 ... 1 4 ... 2 ... 7 11 ... 10 ... ... 5 ... 15 18 2 15 ... ... 2 ... 19 25 ... 14 ... ... 1 ... 15 Mar. 4 1 9 ... ... 6 ... 16 11 1 2 ... ... 1 ... 4 18 ... 2 ... 1 3 ... 6 25 ... 1 ... ... ... ... 2 April 1 ... 2 1 ... 2 ... 5 8 ... ... ... ... 1 ... 1 15 ... ... ... 1 1 ... 2 22 ... 2 1 ... 1 ... 9 29 ... 2 ... ... ... ... 2 May 6 ... 1 ... ... ... ... 1 13 ... 1 ... ... ... ... 1 20 ... 4 1 ... 2 ... 7 27 ... 4 ... 3 1 ... 8 June 3 ... 1 ... ... ... ... 1 10 ... 2 ... ... ... ... 2 17 ... 1 ... ... ... ... 1 24 2 1 ... ... 1 ... 4 July 1 1 ... ... ... ... ... 1 8 ... 4 ... 1 ... ... 5 15 ... 8 ... ... ... ... 8 22 ... 4 ... 1 ... ... 5 29 ... 2 ... ... ... ... 2 Aug. 5 ... 1 ... ... 1 ... 2 12 ... 2 ... ... ... ... 2 19 ... 1 ... ... 1 ... 2 26 ... 1 ... ... 1 ... 2 Sept. 2 ... 2 ... 1 ... ... 3 9 ... ... ... 1 ... ... 1 16 ... ... ... ... 1 ... 1 23 ... 1 ... ... ... ... 1 30 ... ... ... ... ... ... 0 Oct. 7 ... 1 ... ... ... ... 1 14 1 ... 1 ... ... ... 2 21 ... ... 1 1 ... ... 2 28 ... 2 3 ... 1 1 7 Nov. 4 ... ... 5 ... 1 ... 6 11 2 ... 3 ... ... 1 6 18 ... ... 1 ... ... ... 1 25 ... ... 1 ... ... ... 1 Dec. 2 2 ... 1 ... ... ... 3 9 ... 1 ... ... ... ... 1 16 ... ... ... ... ... ... 0 23 ... ... ... ... ... ... 0 31 ... ... ... ... 2 1 3 18 115 26 10 50 3 222 23 Epidemic Enteritis. Summer Diarrhoea. Finding this disease was becoming somewhat prevalent in the early part of August, the Council on my recommendation caused 2,000 handbills to be distributed among the cottages, giving information in a simple form as to the precautionary measures necessary to be taken to prevent this Disease. Neither myself or your sanitary staff have spared time or trouble that we might cope with this disease, and secure the removal of all conditions that might be calculated to favour its spread. The following cases of infectious disease were removed to the Enfield and Edmonton Joint Board's Isolation Hospital, Winchmore Hill:— Scarlet Fever 243 Diphtheria 155 Enteric Fever 1 399 In addition to the above, there were removed in the early part of the year, 18 cases of diptheria, removed to the Cheshunt Isolation Hospital, and 12 to the Walthamstow Isolation Hospital. Method of Disinfection—Rooms, Etc. Rooms are sprayed with formalin, and also fumigated with Formalin gas or sulphur. Owners or occupiers are also required to strip and cleanse rooms in all cases where patients 24 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-Lyonssteam disinfecting apparatus. This apparatus stands at the Council's sewage farm. 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 wells still in use. I examined 15 samples from these, and found 10 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, or to thoroughly cleanse the source of supply and thus obtain a supply of pure water. Milk and Foods. Particular attention has been paid to the milk supply of the District during the year. 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 slaughterhouses and bakehouses, while a close watch was also kept of the meat slaughtered and sold in the district. I have visited all the cowsheds, dairies, milkshops, bakehouses and slaughterhouses in 25 the District, and where necessary have made repeated inspections, and while in the majority of cases the Bye-laws and Regulations were being generally complied with, I found the strictest supervision was required in some cases, where the traders and others did not appear to fully realize the necessity of the absolute cleanliness and care so necessary to be observed in the business as caterers for the public, particularly impressing upon Cowkeepers the importance of grooming their cows, the washing of hands, and wearing of overalls by the milkers. On my recommendation the Council issued to all engaged in the milk business two leaflets, giving valuable information as to sources of contamination of milk, and the precautions necessary to secure a clean milk supply. The Council also made an arrangement for the veterinary examination of all milch cows (of which there are some 400) in the District every six months, with a view to the discovery of any cases of Tuberculous Disease of the udder, and the following are copies of the Veterinary Surgeon's reports for 1909:— "Feb. 20th, 1909.—I beg to report that I have com"pleted the inspection of the milch cows in the district. "I found several cases of diseased udders, of which I "made a careful examination, and took a sample of the "milk. These I examined bacteriologically, and the re"sult showed that there is no case of tuberculosis of the "udder among the cows inspected." "Dec. 11th, 1909.—I beg to report that I have com"pleted the inspection of the milch cows in the district. "I found several cases of the ordinary diseases of the "udder, as would naturally occur among such a number "of animals, but none of a tuberculous nature. In the "few suspected cases I took samples of the milk, and made "a bacteriological examination, but found no trace of the "Tubercle Bacillus." 26 "The cows, generally, are in excellent condition, and "well cared for. As it is customary for the owners to "dispose of unthrifty and unprofitable animals, and at "this period of the year they have been at grass for some "months their health is naturally satisfactory." A close watch is kept on the condition of the meat and other articles of food sold in the District, and it is the duty of Mr. Fred Wilson (the First Assistant to the Inspector of Nuisances,) who holds the certificate of the Royal Sanitary Institute for Meat and Foods, to visit the slaughterhouses, (of which there are seventeen in the District), as far as possible during the times of slaughtering, and also see that the meat exposed for sale in the various shops and markets is of good quality. During the year fifteen parcels of organs found to be diseased were condemned and destroyed. House Refuse. This work is carried out by the Council's own staff, a weekly collection being made now throughout the greater part of the District. Part of the stuff collected is disposed of to brickmakers, and the remainder taken to the Council's depot at Carterhatch Lane, where it is levelled and covered with earth. The Council is now taking steps to obtain land suitable for the erection of a dust destructor. Nuisances, Etc. It will be seen from the particulars given in the Report of the Inspector of Nuisances that a large amount of work has been carried out during the year in securing the removal of nuisances, and improvements in the sanitary condition of the dwellings. 27 There are no offensive trades, or Common Lodging Houses in Enfield. Schools. A close watch has been kept on the sanitarycondition of the public Elementary Schools in the District. Several of the Schools have been specially disinfected, where it was deemed necessary; and the relations between the School Medical Officer and myself have been most harmonious and satisfactory. Infectious Disease. When a case of Infectious Disease is notified, the house is at once visited and full enquiries made, and all necessary steps taken to secure the isolation of the patient either by immediate removal to Hospital or otherwise, disinfectants are supplied, also the necessary examination and disinfection of premises carried out. Other children in the house are excluded from School, and all other precautions which may in my opinion be necessary are at once carried out. It will be of interest for me to mention that notifications are usually left by hand, or come by post to the Offices, but in many cases the Medical man in attendance telephones immediately on becoming aware that he has an infectious case to deal with. The following special arrangements have also been made to remove and deal with cases notified out of office hours:—An Inspector also attends when the Office is closed, on Saturdays at 5 p.m., and on Sundays and Holidays at 9.30 a.m. and 4 p.m. In the intervals Notifications and Swabs may be left with the Caretaker at the main entrance. 28 Pulmonary Tuberculosis. Following the coming into force of the Public Health (Tuberculosis) Regulations, 1908, and the adoption by the Council in May last of a scheme providing for the voluntary notification by Medical men of cases of Pulmonary Tuberculosis, it was agreed to adopt the following suggestions made by me:— (a) That in all cases, following the removal of a patient, the disinfection of infected premises and bedding, etc. be carried out by the Council's staff, as in the case of other infectious diseases. (b) That patients and those having charge of them be supplied with suitable disinfectants, and instructed as to the disposal and destruction of all infectious material; also that portable pocket spittoons be supplied for the use of patients. (c) That a hand-bill containing suitable information and instructions respecting Pulmonary Tuberculosis and the precautions to be taken against the spread of infection, be prepared and left at the houses where cases are notified. Eleven cases have been notified under the Regulations, and 34 under the arrangement for voluntary notification, and there have been five deaths of the former, and seven of the latter. Of the cases notified, I have verified twelve by bacteriological examination of the sputum. Pollution of Streams. Turkey Street brook and other streams in the District are kept under observation by the sanitary staff, but the only source of pollution found necessary to deal with has been the 29 lessness of some of the inhabitants in emptying slop water down surface drains which communicate with the brooks, instead of into those connected with the proper sewers. In such cases a warning has usually been found sufficient to put a stop to the practice. Sewerage. The fifth filter at the Sewage Farm, referred to in my last year's Report, is completed, and has been brought into use. Mr. R. Collins, the Council's Surveyor, also informs me that the following new sewers, or extensions, were in course of construction at the end of the year:—9-in. sewers in Main Avenue,. Old Road, St. George's Road and The Ridgeway, and an 18-in. sewer in Turkey Street. The new culvert in Cecil Road, Sarnesfield Road, Church Street and Little Park was completed, and is now being extended to Parsonage Lane. A new surface water culvert, three feet diameter, has also been laid from Harman Road, Lincoln Road, to Cecil Avenue; and a new surface water drain constructed at Cockfosters Road. Hounsden Gutter, on the Winchmore Hill Estate, has been diverted, and 600 feet of large concrete culvert constructed. Private Roads and Streets. The following private roads have been made or laid out:— Mafeking Road, Southbury Road, Sketty Road (extension); Station Avenue, Lincoln 30 Road; The Grangeway, Winchmore Hill; The Chine, Winchmore Hill (extension); Old Park Ridings; Armfield Road, Lancaster Road (part of); Vera and Rosa Avenues, Winchmore Hill Estate (parts of). The following streets have been dealt with under Section 150 of the Public Health Act, and properly metalled, channelled, and paved, etc.: —Oxford, Northampton and Clarence Roads, Ponders End, Burleigh Road, Bush Hill Park. Duck Lees Lane, Ponders End; Lincoln Road, Bush Hill Park; and the road at the corner of Baker Street and Lancaster Road have been widened, thus effecting much needed improvements. During the year allotments have been provided at Lavender Hill, Holtwhites Hill and against Albany Park, Enfield Lock. Land has also been purchased for allotments at Brimsdown, Enfield Highway. On the Winchmore Hill Estate one mile of new streets and two miles of sewers are in course of construction. 164 new houses have been certified as completed, and fit for human habitation. 19 buildings of the warehouse class have also been built. The information re rainfall and sunshine I have been glad to cull from the valuable records supplied regularly to the "Enfield Observer" by Mr. John McEwan, F. R. Met. Soc., of "Carisbrooke," Bycullah Park. It now only remains for me to express once 31 more my gratitude for the kindly assistance I have received during the year from your Sanitary Inspector, Mr. A. J. Munro, who has most willingly rendered me all the service he could in furthering the interests of the District. I am also glad to acknowledge the zeal and attention paid to their duties by all the other members of the Sanitary staff, who I know have ably and readily co-operated in all that has been done. Yours obediently, William Pennefather Warren, D. P. H. Medical Officer of Health. 33 Public Offices, Enfield, Feb. 23rd, 1910. Report of the Inspector of Nuisances for year 1909. 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, 1909, giving particulars of the work done under my supervision in connection with your Sanitary Department. Inspections. Houses inspected from house to house „ „ in connection with Infectious Disease 941 639 Other houses and premises inspected 536 Factories inspected 42 141 workshops and workplaces including 12 laundries 272 Outworkers' premises inspected 49 44 bakehouses in the district, of which 41 are in use 289 17 slaughter-houses, inspected frequently. Total number of visits 204 34 cowsheds inspected frequently. Total number of visits 193 84 dairies and milkshops inspected. Total number of visits 261 28 schools inspected frequently. Total number of visits 267 74 shops where ice cream is made. Total number of visits 146 Carried forward 3,839 34 Brought forward 3,839 Public-house urinals inspected 40 Conveniences at railway stations inspected 8 Fish shops. Total number of visits 79 Employment of Children Act. Visits 59 Other inspections, including works in progress, also visits in connection with cases of infectious disease, &c. 13,651 Smoke observations 49 17,725 Notices issued:— For repairs to drains, and abatement of nuisances 193 Under Infectious Diseases Act:— To occupiers 317 To schools 3,833 4,150 4,343 Letters sent:— In lieu of notices 1,143 Other letters 1,973 3,116 Houses and parts of houses cleansed, repaired, etc. 288 Roofs repaired 107 Cutters and downpipes repaired 293 Cesspools emptied 185 House drains cleared, repaired, etc. 336 House drains tested, examined, etc. 494 35 House drains reconstructed 69 Soil-pipes and drains ventilated, including repairs to ventilators 74 Closets provided with proper flushing cisterns or water supply 212 New closets provided 13 Closets repaired, covered, cleansed, etc. 251 Storage cisterns repaired, covered, cleansed, etc. 100 Water laid on or restored 33 Samples of water taken 15 New storage cisterns provided 13 Wells cleansed 2 Yards paved, or existing paving made good 181 Ventilation provided under ground floors, and causes of dampness removed 58 Dustbins repaired, or new ones provided 225 Manure heaps removed 67 Fowls and other animals removed 25 Other nuisances abated 94 Ditches cleaned out 3 Cases of ovecrowding abated 26 Houses disinfected:— After infectious disease 483 After Phthisis 26 509 Rooms stripped and re-papered, etc., after occupation by cases of infectious disease 113 Articles of clothing, bedding, etc., disinfected after infectious disease 5,183 Articles of clothing, bedding, etc., destroyed 11 Carried forward 5,194 36 Brought forward 5,194 Articles of clothing, bedding, etc., disinfected after phthisis 165 Articles of clothing, bedding, etc., destroyed after phthisis 3 168 Articles of clothing, bedding, etc. disinfected after cancer 8 Total number of articles disinfected or destroyed 5,370 Library books disinfected 114 Cases of Scarlet Fever removed to hospital 248 Cases of Diphtheria do. 185 Cases of Enteric Fever do. 1 Cases of Puerpural Fever removed (one to Cottage Hospital and one to the London Hospital) 2 436 Gipsy vans removed from district 319 Articles or parcels of unsound food destroyed 21 Removal of House Refuse. The removal of house refuse has received close attention, 6,130 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 1909 there were 129 workshops, 12 laundries and 44 bakehouses (including one underground bakehouse) registered. These have all been inspected several times 37 in the year, and the following contraventions were found requiring action, which was taken:— W.C.s with defective flushing put in order 20 Workshops and bakehouses cleansed and limewashed 31 Other nuisances abated 16 Homework. Twelve lists have been received giving addresses of outworkers, also 36 addresses of outworkers from other districts. Thirteen addresses of outworkers have been forwarded to other districts. An inspection was made of the residences of all outworkers living in this district. In May last proceedings were, by your instructions, taken in the Police Court against a person, whose name and address had been received as an outworker, for obstructing your Sanitary Inspector and refusing to admit him for the purpose of inspection. The case was heard in the absence of defendant, and a fine of three pounds and costs, including 10/6 towards solicitor's expenses imposed. Employment of Children Act, 1903. During the year 264 names were received of children employed out of school hours, and in 142 cases contraventions of the Bye-laws were found and remedied. Milk. Frequent inspections have been made of the dairies and milkshops in the district, in order to see that the requirements of the Dairies, Cowsheds 38 and Milkshops Orders, and the Regulations in forcein the district are complied with. Ice Cream. 74 shops where ice-cream was made or sold were inspected during the summer, 146 visitsbeing made to them, and where necessary instructions given in regard to the cleansing of utensilsand 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. 21 parcels of organs were found to be affected with disease. These were surrendered by the owners and destroyed. 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 ownerscould secure the return of the money paid, from the wholesale traders:— Jan. 15th 1 trunk of coal fish. Aug. 9th 1 trunk whiting. Sept. 2nd 1 trunk haddocks. Oct. 18th 1 basket of shrimps. Oct. 27th 2 boxes of mackerel. Oct. 27th Case of 50 mackerel. Oct. 27th 3 boxes mackerel. 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 39 fied. In all cases where possible the work was tested with water during progress, and a final test with smoke and water applied on completion. 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. I am glad to report that there has been an increased number of inspections of dwellings during the past year, with the result that a larger number of houses have been repaired and cleansed, also causes of dampness and other insanitary conditions removed. 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 am glad to be able to again take the opportunity afforded by this report to acknowledge and thank them for the continued help and co-operation given me throughout the year, and for the real interest displayed in their work. 40 I must also include in this acknowledgment Mr. J. Ellis, and the other members of the outdoor staff connected with this Department. I'am, Gentlemen, Your obedient servant, A. J. MUNRO, M.R. San. I. Inspector of Nuisances.