SouG006 Southgate Urban District Council. REPORT OF THE Medical Officer of Health FOR THE YEAR 1906, BY SIDNEY RANSOME, B.A., M.B., B.C., D.P.II., Cantab., Fellow of the Royal Institute of Public Health, Member cf the Incorporated Society of Medical Officers of Health, MEDICAL OFFICER OF HEALTH — 1907 — PRINTED AT THE "BARNET PRESS" OFFICE To the Members of the Southgate Urban District Council. Gentlemen, I have the honour to present to you my Report for the year 1906, to which is appended the Report of the Sanitary Inspector, Mr. J. W. H. Brown, which, as usual, constitutes an excellent record of good and useful sanitary work done by him and his assistant during the year, and to whom my thanks are due for valuable assistance in compiling this Report. I should also like to tender my thanks to the Health and Hospital Committee for their unfailing courtesy and support throughout the year. I am, Gentlemen, Your obedient Servant, A. SIDNEY RANSOME. February, 1907. 4 DESCRIPTION AND TOPOGRAPHY OF THE DISTRICT. THE Urban District of Southgate is formed by a number of hamlets, previously—and some of them even now—called "villages.'' It is partly situated on what is sometimes called the Northern Heights, about eight miles from London, and is rapidly becoming essentially suburban in character. The District comprises an area of 3,596 acres, and may be said to consist of three valleys, running from west to east, the northern areas being somewhat higher than the southern, and the whole consisting of very undulating ground dipping off to a rather flat area on the eastern boundary, adjoining the Edmonton district. The highest Ordnance level is on the Enfield Road, and is 302 feet; while the lowest is near the south-eastern boundary, and is 61 feet. The subsoil consists of various clays with large pockets of gravel and sand. On the south side is a bed of brick earth overlying a deep bed of gravel, which forms excellent building land, on which a building estate has recently been opened. Beneath these strata are beds of London clay, black sand, and chalk, more or less water bearing, and from which the deep wells and borings of the New River Company derive their supply. The District may be roughly divided into four localities : (1) Southgate, (2) Winchmore Hill, (3) a large part of New Southgate and Bounds Green, and (4) Palmers Green and a large part of Bowes ; hitherto more or less distinct localities, but which, by continually and rapidly growing and extending, are gradually overlapping and becoming merged one into the other, more especially the two latter. The District may, however, now be more conveniently dealt with in the two county divisions of North and South Southgate, the dividing line of which passes from the Edmonton boundary in Hedge Lane, along Hedge Lane, and up Bourne Hill to Chase Side Corner, Southgate. This is a more or less natural boundary line, with the major part of Southgate and Winchmore Hill, the more rural part of the District, on the north side of the line, and Palmers Green, Bowes Park, and New Southgate, the more urban part of the district, on the south side. For the purposes of local administration the District has recently been divided into four wards, which correspond roughly with the four localities above mentioned, two wardi in North Southgate and two in South Southgate. 5 POPULATION. The census returns of 1901 showed that in this District the number of inhabitants to each occupied house averaged from 5.1 to 5.3, according to the locality. Taking this as the basis of calculation, the population at Midsummer, 1906, was 25,500, an increase of 3,100 over that of the previous year. This is a smaller increase by 300 than that of the previous year, due to the fact that a somewhat less number of new houses were erected and occupied than in the previous year, which was a record in this respect. As the number of houses are now apportioned to each ward instead of to each locality, it is difficult to get data for the separate localities as hitherto, and as they are gradually becoming merged one into the other, and so losing their distinctive characteristics, there is little or no importance in continuing to do so ; and as the wards correspond roughly with the localities, there is no useful purpose to be served in getting out separate statistics for each separate ward. On the other hand, data for North and South Southgate are easily and conveniently obtainable, and as the District falls naturally into these two dsvisions, each with its own (up to the present) distinct characteristics, it is better for statistical purposes to deal with it in this way. The population of North Southgate was 8,700, whilst that of South Southgate was 16,800. The natural increase of the population by excess of births over deaths was 286, exactly the same as that of the previous year. BIRTHS.—BIRTH=RATE. During the year 562 births were registered, an increase of 100 on the preceding year. This gives a birth-rate of 22.0 per 1,000 of the population, an increase of 1.4 per 1,000 on the preceding year, which was the lowest on record for this district. The average rate for the 10 years 1896 to 1905 was 23'4. The birth-rate for North Southgate was 20.9, and that for South Southgate 22.6. The birth-rate in England and Wales in 1906 was 27.0 per 1,000 of the population, which is 0.2 below the rate for the previous year, and lower than the rate in any other year on record; compared with the average in the previous 10 years, the birth-rate in 1906 shows a decrease of 1.7. 6 MORTALITY. General Mortality and Death-rate—The number of deaths which occurred in the district during the last year was 234. To these must be added the deaths of 47 "residents " who died outside the district—14 in Edmonton Union, 8 in the County Asylum, Napsbury, 5 in the Great Northern Hospital, 5 in the Enfield Isolation Hospital, 2 in the Passmore Edwards Hospital, Wood Green, and the remainder in sundry other hospitals and institutions. The deaths of 8 "non-residents" who died in the District (in the Metropolitan Asylums Board Hospital, at Winchmore Hill) must be subtracted. The nett total of deaths belonging to the District was 276. The crude or recorded death-rate was therefore 10'8 per 1,000 of the population. In order to obtain the corrected death-rate, for the purposes of accurately comparing the death-rate with that of other Districts, and so on, it is necessary, in addition to the above corrections, to take into consideration the age and sex distribution of the population. The "factor for correction" for this District is 1.045. The corrected rate is obtained by multiplying the crude or recorded death-rate by this factor. The corrected death-rate was 11.2, an increase of 3.0 per 1,000 on the rate of the preceding year (the lowest rate on record for this District), and .9 above the average corrected rate for the 10 years 1896 to 1905. The increase in the death-rate was due chiefly to two causes; firstly, to the number of deaths from infantile diarrhœa, which was about treble the average number, due to the excessively hot and dry summer and autumn ; and, secondly, to the serious outbreak of typhoid fever in New Southgate, which resulted in 9 deaths. It was also in part due to a somewhat increased number of deaths from general diseases throughout the year as compared with the previous year, for which there is nothing special to account for. As compared with the previous year, the most noticeable increases, apart from Diarrhoea and Typhoid Fever, were recorded from the following causes:—Cancer, which was the cause of 9.7 per cent. of the total number of deaths, as against 6.7 per cent.; Heart Diseases, 9.7 per cent. as against 8'9 per cent.; Alcoholism, 3.6 per cent. as against l.l per cent.; and Premature Birth, 4.3 per cent. as against 3.3 per cent. 7 The death-rate for England and Wales was 15.4, which is 0'2 above the rate for the previous year, and 1.4 below the average rate for the previous 10 years. Infantile Mortality.—There were 60 deaths of infants under 1 year of age, which gives an infantile death-rate of 104.9 per 1,000 births registered, as against 77.7 in the preceding year, 79.3 in 1904, and 87.1 in 1903. The average rate for the 10 years 1896— 1905 was 102'4. This increase in the infantile death-rate was due to the large number of deaths from summer Diarrhoea, compared with the previous few years. Excepting this, there was no incidence of any particular disease upon infants under 1 year of age; and apart from the excess of deaths from diarrhoea, the infantile death-rate would have been even lower than that of the previous year, which was the lowest rate on record for this District. In Table 1B. are set forth the causes of death of infants under 1 year of age in weeks and months. The infantile death-rate in North Southgate was 109'8, whilst that of South Southgate was 105.2. There were comparatively more deaths in North Southgate than in South Southgate from diarrhoea, which accounts for the difference in the death-rate. The infantile death-rate in England and Wales was 133 per 1,000 births registered, which is 5 per 1,000 above the rate for the previous year, and 14 per 1,000 below the rate for the previous 10 years. Senile Mortality. —Among persons of 70 years of age and over 54 deaths occurred, and of these 17 were 80 years of age and over. This is a proportion of 19 per cent. of the total number of deaths at all ages, as against 27 per cent. in the preceding year, and 22.8 in 1904. The percentage of deaths of persons of 70 years of age and over in North Southgate was 27, whilst that of South Southgate was only 15. Zymotic Mortality.—This includes the deaths from the seven principal zymotic diseases, viz.:—Smallpox, Scarlet Fever, Diphtheria, Typhoid Fever, Measles, Whooping Cough, and Diarrhoea. This rate affords useful evidence as to the general healthiness of the District, and as to the efficiency of its sanitary administration. There were 48 deaths from these disease, as follows:—Scarlet Fever, 2; Diphtheria, 5 ; Typhoid Fever, 9; Measles, 1 ; Whooping Cough, 4; and Diarrhoea, 27. The Zymotic death-rate was therefore 1'8 per 1,000 of the population, as against .71 in the preceding year, 79 in 1904, and 10 in 1903. 8 The average rate for the 10 years 1896 to 1905 was 1.3. This increased rate was due to the large number of deaths from Diarrhoea and Typhoid Fever as compared with previous years. If the number of deaths from these two causes had not been above the average number of recent years, the rate would have been well below the average for the previous year. The Zymotic death-rate for North Southgate was 1.4, whilst that for South Southgate was 2.0. The Zymotic death-rate in England and Wales was 1.73. The Public Mortuary.—During the year 12 bodies were deposited in the Mortuary, as against 17 in the preceding year and 9 in 1904. 9 Inquests held during the Year 1906 on Deaths occurring the District. No. Month. Sex. Age. Condition of Life. Cause of Death. 1 February Male 69 Labourer Hemorrhage of the Brain. 2 February Male New Born Infant Accidental death. 3 February Male 71 Labourer Natural causes. 4 March Male 55 School Master Heart disease. 5 April Male 2 Infant Accidental death. 6 May Male New Born Infant Natural causes. 7 June Male 75 Master Mariner Heart disease. 8 July Male 14 — Accidental death. 9 August Male 69 Independent Natural causes. 10 August Male 34 Labourer Natural causes. 11 October Male New Born Infant Accidental death. 12 October Female New Born Infant Accidental death. 10 Table I Vital Statistics of Whole District during 1906 and Previous Years. Year. Population estimated to Middle of each Year Births Total Deaths Regis. tered in the district. Total Deaths in Public Institutions in the district Deathsof Non.residents registered in Public Institutions in District Deaths of Residents registered in Public Institutions beyond District Nett Deaths at all ages, belonging to District Under 1 Year of Age. At all Ages Number. Rate* Number Rate per 1,000 Births registered Number Rate* Number. Rate.* 1 2 3 4 5 6 7 8 9 10 11 12 13 1896 12,500 315 25.2 25 80 117 9.3 14 14 † 103 8.2 1897 13,000 326 25.2 48 147 170 13.0 12 12 ... 158 12.1 1898 14,000 310 22.1 37 119 161 11.5 11 11 ... 150 10.7 1899 14,500 366 25.2 51 140 192 13.2 10 10 ... 182 12.5 1900 15,000 320 21.3 38 118 153 10.2 2 2 ... 151 10.0 1901 15,200 375 24.6 35 93 140 9.2 6 6 8 142 9.3 1902 15,800 396 25.0 33 83 166 10.5 7 7 4 163 10.3 1903 17,000 367 21.5 32 87.1 142 8.3 3 3 7 146 8.5 1904 19,000 441 23.4 35 79.3 181 9.5 10 10 11 182 9.5 1905 22,400 463 20.6 36 77.7 162 7.2 13 13 29 178 7.9 Averages for years 1896.1905 15,800 367 23.4 37 102.4 158 10.1 8.8 8.8 ... 154 9.9 1906. 25,500 562 22.0 60 104.9 234 9.1 8 8 47 276 10.8 * Rates in Columns 4, 8, and 13 calculated per 1,000 of estimated population. Note.—The deaths included in Column 7 of this Table are the whole of those registered during the year as having actually occurred within the district or division. The deaths included in Column 12 are the number in Column 7, corrected by the subtraction of the number in Column 10 and the addition of the number in Column 11. By the term "non-residents" is meant persons brought into the district on account of sickness or infirmity, and dying in public institutions there; and by the term "residents" is meant persons who have been taken out of the district on account of sickness or infirmity, and have died in public institutions elsewhere. The "public institutions" to be taken into account for the purposes of these Tables are those into which persons are habitually received on account of sickness infirmity, such as hospitals, workhouses and lunatic asylums. A list of the Institutions in respect of the deaths in which corrections have been made are given on the next page. Area of District in acres (exclusive of area covered by water). 3,596 Total population at all ages 15,200 Number of inhabited houses 2,980 Average number of persons per house 5.1 At Census of 1901 † No returns received until 1901, and then only those relating to the Edmonton Union. Full returns relating to all deaths of "Residents" outside the District not received until 1905. 11 I. II. III. Institutions within the District receiving sick and infirm persons from outside the District. Institutions outside the District receiving sick and intirm persons from the District. Other Institutions, the deaths in which have been distributed among the several localities in tlieDistrict. Metropolitan Asylum Edmonton Union. Board Hospital, Winchmore Hill. Middlesex Asylum, Napsbury. Great Northern Hospital, Holloway. Passmore Edwards Hospital, Wood Green. Etc. Is the Union Workhouse within the District? No. Table III. Cases of Infectious Disease Notified during the Year 1906. Notifiable Disease. Cases Notified in Whole District. Total Cases Notified in Each Locality. No. of Cases Removed to Hospital from Each Locality. At all Ages. At Ages - Years. North Southgate. South Southgate. North Southgate. South Southgate. Under 1. 1 to 5. 5 to 15. 15 to 25. 25 to 65. 65 and upwards Small-pox .. .. .. .. .. .. .. .. .. .. .. Cholera .. .. .. .. .. .. .. .. .. .. Diphtheria 31 .. 9 15 3 4 .. 11 20 6 14 Membranous Croup .. .. .. .. .. .. .. .. .. .. .. Erysipelas 17 .. 1 1 3 8 4 6 11 .. .. Scarlet Fever 85 .. 15 62 7 1 .. 31 54 21 36 Typhus Fever .. .. .. .. .. .. .. .. .. .. .. Enteric Fever 79 .. 10 36 12 21 .. 3 76 2 66 Relapsing Fever .. .. .. .. .. .. .. .. .. .. .. Continued Fever .. .. .. .. .. .. .. .. .. .. .. Puerperal Fever 2 .. .. .. 1 1 .. .. 2 .. .. Plague .. .. .. .. .. .. .. .. .. .. .. Totals 214 .. 35 114 26 35 4 51 163 28 93 Isolation Hospital—Tottenhall Road, Palmers Green (in the District), provided by the Southgate Urban District Council, 13 Table IIIa. Cases op Infectious Disease Notified during each Month of the Year 1906. Notifiable Diseases. Smallpox. Scarlet Fever. Diphtheria. Typhoid Fever. Puerperal Fever. Erysipelas. Totals. January .. 8 8 .. 1 .. 17 February .. 5 1 .. .. 1 7 March .. 6 .. .. .. .. 6 April .. 9 .. .. .. 4 12 May .. 4 3 2 •• .. 9 June .. 6 1 2 .. 2 11 July .. 12 2 .. 1 2 17 August .. 5 1 2 .. 1 9 September .. 3 .. 40 .. .. 43 October .. 14 1 26 .. 2 43 November .. 9 8 6 .. 2 25 December .. 5 6 1 .. 3 15 Totals .. 85 31 79 2 17 214 Table IV. Causes of and Ages at Death during the Year 1906. Causes of Death. Deaths at subjoined ages of "Residents" whether occurring in or beyond the District. Deaths at all ages of "Residents" belonging to localities whether occurring in or beyond the District. Total deaths whether of "Residents" or "Non-Residents 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. North Southgate. South Sou hgate. Small Pox .. .. .. .. .. .. .. .. .. .. Measles 1 .. 1 .. .. .. .. .. 1 .. Scarlet Fever 2 .. .. 2 .. .. .. .. 2 8 Whooping Cough 4 4 .. .. .. .. .. 1 3 .. Diphtheria and Membranous Croup 5 .. 4 1 .. .. .. .. 5 .. Croup 1 .. 1 .. .. .. .. .. 1 .. Enteric Fever 9 .. .. 3 1 5 .. 1 8 .. Other Fever, continued .. .. .. .. .. .. .. .. .. .. Epidemic Influenza 4 1 .. .. .. 3 .. 1 3 .. Diarrhœa 27 23 3 .. .. 1 .. 11 16 .. Enteritis 2 .. .. .. .. 1 1 .. 2 .. Puerperal Fever 2 .. .. .. .. 2 .. .. 2 .. Erysipelas .. .. .. .. .. .. .. .. .. .. Other Septic Diseases .. .. .. .. .. .. .. .. .. .. Phthisis (Pulmonary .. .. .. .. .. .. .. .. .. Tuberculosis) 9 .. 1 .. 2 6 .. 3 6 Other Tubercular Diseases 9 1 3 2 2 1 .. 3 6 .. Cancer (malignant disease) 27 .. 1 .. .. 17 9 7 20 .. Bronchitis 13 3 2 .. .. 1 7 4 9 .. Pneumonia 12 2 .. .. 2 5 3 2 10 .. Pleurisy .. .. .. .. .. .. .. .. .. .. Other Diseases of Respiratory Organs 5 2 2 .. .. .. 1 1 4 .. Alcoholism—Cirrhosis of Liver 10 .. .. .. .. 9 1 2 8 .. Venereal Diseases .. .. .. .. .. .. .. .. .. .. Premature Birth 12 12 .. .. .. .. .. .. 10 .. Diseases and Accidents of Parturition 1 .. .. .. .. 1 .. .. 1 .. Heart Diseases 27 .. .. .. .. 16 11 9 18 .. Accidents 6 .. 1 1 .. 3 1 .. 4 .. Suicides .. .. .. .. .. .. .. .. .. .. Senile Decay 31 .. .. .. .. .. 31 17 14 .. Diseases of Nervous System including Apoplexy and Convulsions 19 3 2 .. .. 7 7 7 12 .. Wasting and Debility from Birth including Developmental Defects 5 5 .. .. .. .. .. .. 5 .. All other causes 33 5 .. 5 1 17 5 13 20 .. All causes 270 61 21 14 8 95 77 86 190 8 N.B.—As to the meaning of " Residents " and " Non-Residents" and as to " Public Institutions'" to be taken into account for the purposes of this Table, see note on Table I. 15 Table IVa. Showing the Causes of Death during each of the Four Quarters of the Year, 1906. Cause of Death. 1st Quarter 2nd Quarter 3rd Quarter 4th Quartet Measles .. 1 .. .. Scarlet Fever .. .. 1 1 Whooping Cough 2 2 .. .. Diphtheria 1 .. .. 4 Croup 1 .. .. .. Typhoid Fever 3 6 Influenza 2 1 .. 1 Diarrhoea .. 1 25 1 Enteritis .. 1 1 .. Puerperal Fever 1 .. 1 .. Phthisis 3 1 2 3 Other Tubercular Diseases 3 2 4 .. Cancer 2 7 6 12 Bronchitis 5 6 '2 .. Pneumonia 3 5 3 1 Other Diseases of the Respiratory Organs 1 2 1 1 Alcoholism and Cirrhosis of the Liver 2 4 3 1 Premature Birth 5 3 2 2 Diseases and Accidents of Parturition .. 1 .. .. Heart Diseases 8 8 7 4 Accidents 2 1 2 1 Senile Decay 4 5 10 12 Diseases of Nervous System— Apoplexy and Convulsions 8 5 3 3 Wasting and Debility from Birth, including Developmental Defects 3 .. .. 2 All other Causes 6 4 5 18 All Causes 62 60 81 73 276 Table V. Infantile Mortality During the Year 1906. 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* 14 2 6 1 23 5 2 10 2 7 1 2 4 2 1 1 60 Uncertified i. Common Infectious Diseases— Small-pox Chicken-pox Measles Scarlet Fever Diphtheria: Croup Whooping Cough ... ... ... ... ... ... ... ... ... 1 ... ... 1 1 1 ... 4 ii. Diarrhœal Diseases— Diarrhoea, all forms ... ... 2 ... 2 2 2 8 1 2 1 1 3 1 ... ... 23 Enteritis, Muco-enteritis, Gastro-enteritis Gastritis, Gastro-intestinal Catarrh iii. Wasting Diseases— Premature Birth 6 ... 3 1 10 1 ... ... ... ... ... ... ... ... ... ... 11 Congenital Defects 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... ... 1 Injury at Birth Want of Breast-milk,St'v'tion Atrophy, Debility, Marasmus 1 2 1 .. 4 1 .. 1 .. 1 .. .. .. .. .. .. 7 iv. Tuberculous Diseases— Tuberculous Meningitis Tuberculous Peritonitis: Tabes Mesenterica ... ... ... ... ... 1 ... ... ... ... ... ... ... ... ... ... 1 Other Tuberculous Diseases . v. Other Causes— Erysipelas Syphilis Rickets Meningitis (not Tuberculous) ... ... ... ... ... ... ... ... 1 ... ... ... ... ... ... 1 Convulsions 1 ... ... ... 1 ... ... ... ... ... ... 1 ... ... ... ... 2 Bronchitis 1 ... ... ... 1 ... ... ... ... 1 ... ... ... ... ... ... 2 Laryngitis Pneumonia 1 ... ... ... 1 ... ... ... ... ... ... ... ... ... ... 1 2 Suffocation, overlying 1 ... ... ... 1 ... ... 1 ... 1 ... ... ... ... ... ... 3 Other Causes 2 ... ... ... 2 ... ... ... 1 ... ... ... ... ... ... ... 3 14 2 6 1 23 5 2 10 2 7 1 2 4 2 1 1 60 Population (estimated to the middle of 1906):— District 25,500 Births in the Year legitimate 556 illegitimate 6 Deaths in the Year of legitimate infants 56 illegitimate infants 4 Deaths from all Causes at all Ages 276 • All deaths Certified by Registered Medical Practitioners and all Inquest Cases are classed as " Certified " ; all other deaths are regarded as "Uncertified." 17 Table VI. Comparison of the Rates of the Southgate District with those of England and Wales, the 76 Great Towns, and England and Wales less the 218 Largest Towns. Rates per 1,000 of the Population. Birth-rate. Death-rate. Deaths under 1 year per 1,000 Births. Zymotic Death-rate. Smallpox. Scarlet Fever. Diphtheria. Measles. Whooping Cough. Diarrhœa. England and Wales 27.0 15.4 133 1.73 .00 .1 .17 .27 .23 .87 76 Great Towns 279 15.9 145 2.24 .00 .12 .19 .4 .28 1.16 England and Wales less 218 Largest Towns 26.3 15.1 116 1.18 .00 .08 .16 .14 .19 .52 Southgate District 22.0 11.2 104.9 1.8 .00 .07 .19 .03 .14 1.0 18 INFECTIOUS DISEASES, AND THE MEANS TAKEN TO PREVENT THEIR SPREAD. It will be seen from Table 111, that 214 cases of infectious disease were notified during the year, as compared with 122 in the preceding year, 142 in 1904, and 136 in 1903. Of these 85 were Scarlet Fever, 31 Diphtheria, 79 Typhoid Fever, 2 Puerperal Fever, and 17 Erysipelas. Of these, 51 were notified from North Southgate, and 163 from South Southgate. These 214 cases represent infection in 169 houses, all of which were subsequently disinfected by the Sanitary Authority. In all cases disinfectants were supplied, instructions given as to the carrying out of isolation as efficiently as possible in cases of non-removal to the hospital, and the sanitary condition of the premises inspected. In 8 houses sanitary defects were found, consisting chiefly of defective water-closets and unpaved yards. These defects have all been remedied under the supervision of the Sanitary Authority. The notification of these diseases was, therefore, the means of causing the inspection, apart from ordinary inspections, of 169 premises, and the remedy of insanitary condition in 8. One hundred and twenty-one cases were removed to the Isolation Hospital at Palmers Green. Of these, 53 were Scarlet Fever, 20 Diphtheria, and 48 Typhoid Fever. Twenty-four other cases were removed to other Hospitals as follows:—To the Enfield Isolation Hospital: Scarlet Fever, 2 cases, and Typhoid Fever, 13 cases; to the Passmore Edwards Hospital, Wood Green : Typhoid Fever, 7 cases; and to the Liverpool Road Hospital, Islington: Scarlet Fever, 2 cases. The Infectious Sickness Rate of the District was 8'3 per 1,000 of the population, as against 5'4 in the preceding year, 7.5 in 1904, and 80 in 1903. The rate for North Southgate was 5.8, whilst that for South Southgate was 9.7. This increase in the infectious sickness rate as compared with previous years was due entirely to the outbreak of Typhoid Fever in New Southgate. The difference between the rates of North and South Southgate is due to the same cause. 19 Methods of Disinfection.—(1) For disinfection of rooms, Formalin is used (a) by spraying and (b) with "Paraform" tablets in the "Alformant " lamp. (2) Bedding, &c., is disinfected in the steam disinfecting apparatus established on the premises of the Isolation Hospital. For taking the bedding, &c., to and fro special vans are kept, one for the infected and the other for the disinfected articles. (3) After rooms have been disinfected the wall papers are stripped from the walls and burnt, and ceilings, walls, and all surfaces are thoroughly washed. Diagnosis Outfits.— The diagnosis outfits provided by the Council for the use of the medical practitioners in the District for sending morbid specimens from suspected cases of Diphtheria, Typhoid Fever, and Phthisis to the Lister Institute of Preventive Medicine for bacteriological examination and report have been made extensive use of, and continue to prove of great service in establishing a correct diagnosis in these diseases, to the advantage of the general public health, as well as of those more immediately concerned. During the year 93 specimens were sent and reports received as follows:- Date. Disease Suspected. Report. January 3 Diphtheria Negative. „ 3 Diphtheria (Pseudo) Positive. „ 18 Diphtheria Positive. „ 26 Diphtheria Negative. „ 30 Diphtheria Negative. „ 30 Diphtheria Negative. „ 30 Diphtheria Negative. „ 30 Diphtheria Negative. „ 30 Diphtheria Negative. „ 30 Diphtheria Negative. February 6 Diphtheria Negative. „ 7 Diphtheria Negative. „ 15 Diphtheria Negative. „ 15 Diphtheria Positive. „ 15 Diphtheria Positive. „ 15 Diphtheria Positive. „ 15 Diphtheria Negative. „ 19 Diphtheria Negative. „ 19 Diphtheria (Pseudo) Positive. „ 22 Diphtheria Negative. „ 22 Diphtheria Negative. „ 22 Diphtheria Positive. „ 23 Diphtheria Negative. „ 26 Diphtheria Negative. „ 27 Phthisis Positive. March 6 Diphtheria Negative. „ 6 Diphtheria Positive. „ 14 Diphtheria Negative. April 19 Diphtheria Negative. „ 24 Phthisis Positive. 20 Date. Disease Suspected. Report. May 4 Diphtheria Negative. „ 16 Phthisis Negative. „ 19 Phthisis Positive. „ 30 Diphtheria Positive. „ 31 Phthisis Negative. June 1 Diphtheria Negative. „ 2 Diphtheria Negative. „ 8 Diphtheria Positive. „ 15 Typhoid Fever Positive. „ 16 Diphtheria Positive. „ 23 Diphtheria Positive. „ 28 Diphtheria Negative. „ 29 Diphtheria Negative. „ 30 Diphtheria Positive. July 3 Diphtheria Negative. „ 10 Diphtheria Negative. „ 13 Diphtheria Negative. „ 14 Diphtheria Negative. „ 14 Diphtheria Negative. „ 26 Diphtheria Negative. August 2 Diphtheria Negative. „ 9 Phthisis Negative. „ 11 Typhoid Fever Positive. „ 15 Phthisis Positive. „ 15 Phthisis Positive. „16 Diphtheria Negative. „ 31 Diphtheria Positive. „ 31 Phthisis Positive. September 8 Typhoid Fever Positive. „ 11 Typhoid Fever Negative. „ 13 Typhoid Fever Positive. „ 13 Typhoid Fever Positive. „ 13 Typhoid Fever Positive. „ 17 Typhoid Fever Negative. „ 19 Typhoid Fever Positive. „ 21 Diphtheria Negative. „ 24 Typhoid Fever Positive. „ 26 Typhoid Fever Negative. October 4 Phthisis Positive. „ 9 Diphtheria Positive. „ 9 Diphtheria Negative. „ 10 Typhoid Fever Negative. „ 18 Typhoid Fever Negative. November 5 Diphtheria Positive. „ 6 Diphtheria Positive. „ 7 Phthisis Negative. „ 9 Phthisis Positive. „ 20 Diphtheria Positive. „ 20 Diphtheria Negative. „ 20 Diphtheria Negative. „ 24 Diphtheria Negative. „ 27 Diphtheria Negative. „ 27 Diphtheria Positive. December 3 Diphtheria Negative. „ 3 Diphtheria Negative. „ 4 Diphtheria Negative. „ 4 Diphtheria Positive. „ 5 Diphtheria Negative. „ 7 Diphtheria Negative. 21 Date. Disease Suspected. Report. December 11 Diphtheria Negative. „ 11 Diphtheria Positive. „ 17 Diphtheria (Pseudo) Positive. „ 18 Diphtheria Positive. N.B.—These were not all from different cases, but in many instances, chiefly of Diphtheria, were further specimens taken from the same cases at intervals for re-examination to determine when the case in question ceased to be infectious. In some cases this has to be repeated several times before a negative result is reported. Total.—93 bacteriological examinations, of which 39 gave positive and 54 negative results. Diphtheria Antitoxin.—The supply of diphtheria antitoxin provided by the Council and kept available for use at any time at the Council Offices has been made full use of as occasion required, to the great advantage of those suffering from the disease and the public in general. Handbills concerning Infectious Diseases.—Handbills giving instructions as to the danger of, and precautions to be taken to avoid spreading infection in, cases of Phthisis, Measles, and Whooping Cough—not being notifiable diseases -are always kept in readiness, and have been left at all houses where it came to my knowledge that these diseases were present; and, in the case of the two latter, have also been distributed to all other houses in the immediate neighbourhood. The necessary knowledge as to where the two latter diseases are present is supplied to me chiefly by the School Attendance Officers and the School Authorities. This system of notification of non-notifiable diseases by the School Attendance Officers and the School Authorities, instituted in 1898, continues to work satisfactorily. SMALLPOX. No cases were notified. With regard to the provision of accommodation for the effective isolation of cases of Smallpox reported on in my last Report, the matter at the present time stands thus:— This district is one of the constituent authorities, composed of a number of the Urban and Rural Districts of Middlesex, included in the Provisional Order for the formation of the "Middlesex District Joint Smallpox Hospital," under Section 279 Public Health Act, 1875, for the purchase of Clare Hall Smallpox Hospital, and it is understood that the purchase of the Hospital by the Joint Smallpox Hospital Board is now completed. 22 SCARLET FEVER. There were 85 cases notified from 74 houses, as against 69 in the preceding year, 91 in 1904, and 107 in 1903. Of these, 31 were notified from North Southgate, and 54 from South Southgate. In 4 houses sanitary defects were found, 5 cases were imported, and 2 were secondary cases occurring in houses from which previous cases had been notified. Fifty-three cases were removed to the Isolation Hospital, 2 cases to the Enfield Isolation Hospital, and 2 cases to the Liverpool-road Hospital, Islington. There were two deaths. DIPHTHERIA. There were 31 cases notified from 27 houses, as against 23 in the preceding year, 23 in 1904, and 9 in 1903. Of these, 11 were notified from North Southgate, and 20 from South Southgate. One was an imported case, and 4 were secondary cases occurring in houses from which previous cases had been notified. In one house sanitary defects were found. Twenty cases were removed to the Isolation Hospital. There were 5 deaths. With regard to the secondary case, it is to be regretted that more use is not made of the preventive measure of giving all other occupants, especially children, in a house in which a case has occurred, a prophylactic injection of antitoxin ; as there is no doubt that by this means protection is afforded for at least 3 weeks, and that some, at any rate, of such secondary cases might thus be prevented. TYPHOID FEVER. During the year, 79 cases were notified from 49 houses. Of these, 3 were notified from North Southgate and 76 from South Southgate. Of the latter, 73 were due to the outbreak of Typhoid Fever in New Southgate during September, October, and November. Forty-eight cases were removed to the Isolation Hospital, 13 cases to the Enfield Isolation Hospital and 7 cases to the Passmore Edwards Hospital, Wood Green, whilst the remaining 11 cases were treated in their homes. There were 9 deaths, 2 of which occurred at the Isolation Hospital, 5 at the Enfield Isolation Hospital, 1 at the Passmore Edwards Hospital, Wood Green, and 1 at the patient's own home. 23 A full and detailed report of the outbreak at New Southgate was laid before you in December, of which the following is an abbreviated form:— OUTBREAK OF TYPHOID FEVER IN NEW SOUTHGATE IN SEPTEMBER, OCTOBER, AND NOVEMBER, 1906. Locality.—New Southgate, in the lower part of which the outbreak occurred, has a population of about 5,000. It was formerly a good middle-class residential suburb, but has been steadily deteriorating in the quality of the class of its inhabitants for the last 10 years or more. At the present time the larger part of the population consists of the lower middle and poorer working-classes, chiefly the latter. Many of the larger houses are now let in tenements, and occupied by two or more families. The lower part of New Southgate consists of somewhat mean streets of small houses, some of them accommodating more than one family. These streets of small houses are fairly well built for this class of house, and are in good condition structurally. They are all supplied with water from the Metropolitan Water Company, and are all well drained and well fitted with sanitary arrangements, but they are occupied by a class of persons who, with some exceptions, are dirty in their ways of living, and the houses are consequently for the most part dirty and badly kept. There is a watercourse, Bounds Green Brook, which runs through the valley, immediately to the south and south-east of New Southgate. This brook is polluted by sewage effluent from sewage farms before it enters into the Southgate district. The state of the brook has improved somewhat the last few years, since the Middlesex County Council has caused it to be cleaned out periodically, but it is always more or less under suspicion as a possible cause of ill-health, and is a source of nuisance at times by reason of the smells arising from it. The brook and the banks on either side of it are a •common playground for the children of the neighbourhood, who play about it, and sometimes paddle and bathe in it. Just on the Wood Green side of the boundary line between Wood Green and Southgate districts, there is a large dust-shoot belonging to Wood Green, situated to the northwest of the Great Northern Railway line, between it, Bounds Green brook and the Southgate Gas Company Works, not more than 100 yards from the nearest houses of the infected area. The use of this dust-shoot was discontinued by Wood 24 Green in May last after pressure having been brought to bear upon them by the Southgate Council. Since then it has been covered over by some earth, but for the last two years it has been an extensive breeding ground for flies. Account of the Outbreak,.- No case of Typhoid Fever had been notified during the year in any part of the district until May 20th, when a case was notified from Bowes Park, and another from Alexandra-road, New Southgate. On June 16th 2 cases were notified from one house in Winchmore Hill, and on August 1st 1 case occurred in Old Southgate. Then on August 20th another case was notified from Springfield-road, New Southgate, and from that date up to November 30th 73 cases were notified in the whole district, of which 71 occurred in New Southgate. Table showing Number of Notifications received- during each week during september, october, and November. Week ended. Notifications. Sept. 1st 1 These all occurred in New Southgate, except 2 cases: 1 on Sept. 20th, from Palmers Green, and 1 on Oct. 14th, from Bowes Park. „ 8th 7 „ 15th 4 „ 22nd 8 „ 29th 21 Oct. 6th 7 „ 13th 12 „ 20th 5 „ 27th 1 Nov. 3rd 2 „ 10th 2 „ 17th 2 „ 24th 1 Dec. 1st 0 These 71 cases were notified from 44 separate houses,, which are situated in 10 streets, including the High-road, and streets leading off it on either side ; and the greatest number of houses affected are situated at the lower and southernmost part of High-road and in two short streets, both of which are cul-de-sacs known as Albert-street and Lee-street. Indeed, with the exception of 3 cases in 3 houses in Springfield-road, and 1 case in Station-road, all the cases occurred in a very small area limited by the Bounds Green Brook on the south and south-east, by Alexandra and Upper Park-roads on the north, and by the Great Northern Railway on the west. The diameter of a circle including this area would not exceed 400 yards. 25 A remarkable and predominant feature of this outbreak was its restriction to this very circumscribed area. Investigations made as to origin of the outbreak,:— (l.) Milk Supply.—Of the first 7 cases notified between August 27th and September 7th it was at once noticed that 4 of them obtained their milk supply from the same source. Investigations were therefore at once begun to see if any evidence could be obtained to justify action being taken to prevent the sale of milk from this source. Very careful and exhaustive enquiries were made concerning this milk supply and the milk traced back to its original sources, but no evidence could be obtained that the milk was in any way contaminated either at the farms from which it originated, or in transit, or in process of distribution. During the course of the outbreak this negative evidence was confirmed by the fact that cases were occurring in the special circumscribed area in houses which had not had any milk at all, and also in houses supplied from entirely different sources; while on the other hand no cases were occurring in other parts of the district in which the same milk was being distributed. It appeared evident that the milk supply was not the cause of the outbreak, and therefore no action was taken to stop supply of this milk. (2.) Water Supply.—Attention was next directed to the water supply, which is supplied by the Metropolitan Water Company by a branch from the main which comes down the Green-lanes. Samples of water were taken from taps direct off the main in houses of two of the streets in New Southgate most affected, and analysed both chemically and bacteriologically for evidence of sewage pollution. The reports in both cases were as follows:— "A very good sample of drinking water. No indication whatever of any sewage pollution." (3.) Sewerage.—The sewer, house drains, etc., were inspected and no defects found. The sewerage in this part of the district is on the same dual system of foul sewers and surface-water sewers as obtains throughout the whole district. The sewers and house drains in this neighbourhood are for the most part of recent construction and in good condition. During the summer months they are flushed regularly once a fortnight. (4.) Shell Fish, Fried Fish, and Ice Creams.—The question of shell fish, fried fish, and ice creams as a possible source of infection was also carefully investigated, but little 26 or no evidence could be obtained implicating them. A few of the patients are said to have eaten periwinkles prior to their illness; one patient, the second in that house, was stated to have had both cockles and oysters; and another patient was said to have eaten mussels in London. Fried fish is a more or less regular article of diet among persons living in this neighbourhood. Counting only first attack in houses, there were 19 patients in all who had consumed this form of food prior to their illness. Some of these patients stated that they were in the habit of eating fried fish regularly once or twice or more a week, others only occasionally. No evidence to cast suspicion upon the sources from which the fried fish was obtained, or upon the premises on and conditions under which it was cooked and purveyed, was forthcoming. Six patients had eaten ice-cream before their illness, all from the same source, but no evidence implicating this source could be obtained. Measures adopted to deal with and check the outbreak:— (1). Disposal of Patients and Disinfection.—All cases that would be were at once removed to the Southgate Isolation Hospital. Disinfection of the houses was thoroughly carried out immediately on removal of the patients. The bedding was disinfected in the steam disinfector situated on the premises of the Hospital, and in some cases the bedding, when of little or no value, was destroyed by burning. The cases which remained at home were isolated as well as the circumstances in each case would permit, disinfectants supplied, and instructions given as to the best means to adopt to prevent the spread of infection. When the isolation wards usually devoted to the accommodation of typhoid fever and diphtheria patients, as circumstances require, were full, as many cases as could be received were sent to the Enfield Isolation Hospital. But as further notifications continued to come in, it became necessary to make further accommodation for the patients at the Isolation Hospital. To effect this the scarlet fever block was emptied, and, after very thorough disinfection, converted into typhoid fever wards. Fortunately the district was practically free from all other infectious disease, and there were only two convalescent scarlet fever patients in hospital at the time. These were transferred to the Enfield Isolation Hospital. 27 During the week ended September 29th, when 10 notifications were received in one day, the resources of the Isolation Hospital became strained to the utmost, and no further cases could then be received for a time. Accommodation for some of these cases was found at the Passmore Edwards General Hospital in Bounds Green Road, Wood Green. Meanwhile further temporary accommodation was being provided by the Southgate Council in a disused school building belonging to the Council adjoining the site on which stands the Isolation Hospital. This would have provided for the accommodation of 20 patients, but, fortunately, it was not necessary to use this building, as the notifications now began to diminish in number, whilst the cases first admitted into the Isolation Hospital were beginning to be discharged, which made room for the fresh cases as they occurred. Of the 71 cases in all, 41 were removed to the Isolation Hospital; 14 ,, ,, ,, Enfield Isolation Hospital ; 7 „ „ ,, Passmore Edwards Hospital; 9 remained at home. (2.) A leaflet was drawn up pointing out the precautions to be taken to prevent, as far as possible, the spread of infection, and distributed at every house in the infected area. Analysis and Tabulation of the 71 Cases. These 71 cases occurred in the following streets :— High-road (lower end) 20 cases in 12 houses. Albert-street 18 ,, 10 „ Lee-street 14 ,, 6 „ Curtis-road 6 ,, 3 „ Palmers-road 4 ,, 4 „ Park Cottages 3 ,, 3 „ Springfield-road 3 ,, 3 „ Alexandra-road 1 ,, 1 „ Lower Park-road 1 ,, 1 ,, Station-road 1 ,, 1 „ 71 44 Multiple Attacks in Houses. Of the 44 houses infected two or more cases occurred in the same house in 17 instances, as follows :— In 1 house ... ... 5 cases. „ 2 houses 4 „ each. ,,3 ,, ... ... 3 ,, ,, ,, 11 ,, ... ... 2 ,, ,, 28 As regards these multiple attacks in houses, the question arises as to how many of them may be regarded as secondary, that is due to direct or indirect infection, and how many are simultaneous attacks, probably due to the same infection. In 4 of the 17 houses the date of onset of the disease, or the dale of notification, points to the attacks being simultaneous, viz., in No. 4, Albert-street (first 2 cases). „ 12, Albert-street. ,, 50, High-road. ,, 65, High-road. In the remaining 11 houses the secondary cases occurred at a later date than the first, and may be regarded as most probably due to direct or indirect infection from the previous cases. MISCELLANEOUS NOTES. Number of Persons per Infected House.—The average number was 7—3 adults and 4 children. Dirty Houses.—Thirty-three of the infected houses were described as "dirty" or "in want of cleansing." Flies.—In 40 of the houses a nuisance from the superabundance of flies was complained of. Many of the houses swarmed with them, and after disinfection the floors were in many cases black with dead flies. Milk Supply —In 21 of the houses milk was obtained from one original source, either regularly or occasionally. In 12 houses tinned milk only was used. In 2 „ goat's „ ,, „ „ The remaining 19 houses obtained milk from four other sources. Bathing in Bounds Green Brook.—Nine of the patients —children varying in age from 4 to 12—had bathed and paddled in this brook more or less frequently. These cases were all notified during the month of September. CAUSE OF THE OUTBREAK. I have not been able to determine definitely or conclusively the exact cause of the outbreak. The evidence bearing on the question is as follows :— (I.) Milk Supply.—From facts given it will be seen that 43 percent. of the houses obtained their milk from the same original source. On the face of it, this is a large proportion, and requires explanation. 29 The following facts, however, go a long way towards doing this :— (l.) Milk from the same source as that supplied to these 21 infected houses was supplied also to a large district outside the infected area. In fact, the number of houses in the infected area supplied with this milk formed only a small proportion of the total number of houses supplied with milk from the same source. Outside the infected area only 3 cases of typhoid fever occurred in such houses, and taking the total number of houses supplied with milk from this same source, the number of houses infected becomes reduced to 9 per cent. If this milk supply had been the cause of the outbreak it would have been very improbable that the latter would have been confined to so limited and circumscribed an area, but would have been spread over the whole area supplied with this milk. (2.) These houses were not the first houses attacked, but were distributed evenly throughout the whole of the 44 houses infected during the outbreak. So that it cannot be argued that the outbreak originated in these houses supplied with milk from the same source, and from there spread to the remainder by direct or indirect infection. (3.) The inhabitants of these houses in which the outbreak occurred all belong to the poorer working classes, who only use milk in small quantities in their tea, and occasionally for puddings, and seldom, if ever, drink milk by itself. If milk were the cause of the outbreak it would have been expected that the somewhat better classes, who drink more milk, would have been attacked more than the poorer classes. But this was not the case. (4.) The evidence of the age constitution is also against milk being the source of the disease. Taking primary attacks only, of which there were 41, 22 occurred in those of 15 years and under, and 19 in those of over 15 years. If milk had been the cause of the outbreak one would have expected a larger incidence of the disease in those under 15 years. (II.) Water Supply.—There was no evidence obtained to throw suspicion on the water supply. Moreover, if the water supply had been infected it is certain that the outbreak would not have been confined to the limited and very circumscribed area as it was, but would have been spread over the whole of the area supplied by this water. 30 (III.) Bounds Green Brook.—Owing to the generally polluted condition of this brook, some suspicion at first fell upon it, and the fact that of the first 15 cases which occurred in the first fortnight of September 6 were children who had been in the habit of paddling and bathing in the brook, seemed to lend weight to this suspicion. It was also borne in mind that on one or two occasions in previous years this brook was suspected of being the cause of the occurrence of cases of Typhoid Fever amongst children in this neighbourhood. Then in 1901, out of 9 cases notified from the whole district of Southgate, 7 occurred in New Southgate; and, of these, 5 were children who were reported to have paddled and bathed in, and, in one or two cases, also drunk of the water of this brook. Again in 1902, of 8 cases notified from the whole district, 4 occurred in New Southgate amongst children living in Albert Street and Palmers Road, both close to the brook, which, as previously stated, is a common playground of the children in this neighbourhood. It is possible that some of these 6 children of this present outbreak may have derived the infection from this source, but there is no evidence to show that it was the main or original source of the outbreak. These 6 children, although early cases, were not the first cases notified. The first 4 cases notified, 2 of whom were adults, had not been near the brook at all. Of the first 15 cases notified, these 6 children were the 5th, 6th, 8th, 11th, 14th, and 15th. (IV.) Flies.— For the last 2 years the lower part of New Southgate, in the hollow of the valley, has been infested in the summer and autumn by swarms of flies, more especially this year, when they constituted a great nuisance. Their breeding ground is the previously mentioned dust-shoot. Of the 44 infected houses, 40 were found to be swarming with flies, and 33 of the houses were described as being "dirty" or "in want of cleansing," thus encouraging the nuisance. Above the infected area, on the higher ground, the flies were much less numerous. Now these are the features which, in the history of this outbreak, stand out very prominently before all others; they are by far the most common factor shared by nearly all the houses, over 90 per cent, of the infected houses being infested with flies and 75 per cent, of them being dirty. The inference that some very close connection exists between them and the occurrence of the outbreak is very strong. 31 The importance of flies as a means of conveying infection more especially in epidemic Enteritis and Typhoid Fever, has in recent years been remarked upon by several observers, who have investigated these diseases not only in warm climates but also in this country. It has also been shown that the relative dirtiness of houses is a direct index of the susceptibility of the inhabitants to Typhoid Fever. The life history and habits of flies exactly fit in with the history and cause of this outbreak. It is in July and August that flies attain to their maximum multiplicity, eating voraciously and passing indiscriminately from filth collected in houses, backyards, and streets to various articles of diet in the house. In the class of house in which the outbreak occurred, food is left about on the tables long after meals are over, and little or no care is taken to keep food covered up and protected from contamination by flies. It was at the end of August that the outbreak began, the infection therefore taking place during the earlier and middle part of the month. As the autumn days become cooler, flies become less numerous. They lose vitality and seek shelter in the warmest places available, and cease to settle alternately on refuse matter and articles of food, and by the end of November disappear altogether. In like manner the number of notifications, after increasing throughout September, which was fine and warm, began to decline in October, and throughout that month and November, until during the week ended December 1st they had ceased altogether. (V.) Direct and Indirect Personal Infection.—The class of persons inhabiting the infected area are of the poorer working classes, for the most part dirty in their habits and houses, and with a somewhat high average number of persons per house compared with the rest of the district. They are frequently in and out of each other's houses, thus favouring direct and indirect infection. They are of a class who take little notice of illness and indisposition until it assumes an acute form, and who do not think much about the possibility of any illness being an infectious one unless accompanied by a marked and obvious rash. Nor are they likely to concern themselves or exercise much intelligence about taking steps to prevent the spread of an infectious disease 32 even when aware of its presence. There is evidence to show, in the early part of the outbreak at any rate, the truth of the above statement. Attention has recently been drawn to the influence of direct infection from one patient to another as the chief means of maintaining Typhoid Fever in its endemic form. It may be concluded that this influence may also be at work, though probably to a lesser degree, when Typhoid Fever is epidemic. Attention has also been drawn to the fact that Typhoid infection may exist in a latent form in both children and adults, and that the number of notifications received is not always a correct measure of the amount of Typhoid infection present in a given community. An index of the influence of personal infection may be obtained by working out the proportion of houses in any given epidemic in which more than one case occurs. Thus, taking as instances two extensive epidemics which occurred in Belfast in 1898 and 1903, in which there were about 5,000 and 800 cases respectively, the percentages of houses with more than one case were 13.6 in the first epidemic, and 7.1 in the second, showing that even in a severe epidemic Typhoid Fever has not, as a rule, a very marked tendency to spread to other members of the same house. In the outbreak at New Southgate, however, the percentage of houses in which there were multiple attacks was 38.6; or deducting the 4 houses previously mentioned, in which it was probable that the second attacks were simultaneous with the first, even then the percentage was 25, showing that in this outbreak the influence of personal infection was much more at work than is usually the case. Conclusion.—Taking all the above-mentioned facts and features of the outbreak into consideration, and in the absence of the evidence of any definite source of infection, such as proved infection of the milk or water supply, or contaminated shell-fish, the evidence, in my opinion, shows somewhat conclusively that the origin and spread of outbreak was as follows : — One or more cases of sporadic or endemic origin having occurred in this neighbourhood, and probably undetected till late in the course of the disease, or not at all, and all the factors favouring direct and indirect infection being present, viz., the dust-shoot, the hot dry weather, the swarms of flies, the dirty houses, the class of persons living in the infected area and their habits, and the somewhat thickly-populated 33 neighbourhood, the spread of the disease was caused mainly by direct and indirect infection from house to house (1) by means of the swarms of flies acting as conveyors of infection, and (2) by direct and indirect communication between the occupants from house to house. In this way, and in this way only, in my opinion, can the explanation of the outbreak be found. DIARRHŒA. This disease was very prevalent during August and September throughout the district, and was the cause of 27 deaths. This is a rate of 1.0 per 1,000 of the population, as against .35 in the preceding year, .26 in 1904, .4 in 1903, .3 in 1902, .79 in 1901, and .4 in 1900. The disease was especially prevalent amongst and fatal to infants under one year of age, amongst whom 23 of the 27 deaths occurred. The prevalence of the disease was due to the extremely hot and dry summer. Flies were very abundant, and in some spots occurred in swarms, and there is little doubt that they largely contributed to the dissemination of the disease by conveying infective material to milk and other articles of diet. TUBERCULOSIS. During the year there were 18 deaths from Tubercular diseases, 9 of these being from Phthisis. In all cases of Phthisis that have come to my knowledge, leaflets have been left pointing out fully the nature and danger of the disease, and the means to be taken for the prevention of the spread of infection to others; and where rooms occupied by consumptive persons have been evacuated by death or otherwise, a visit has been paid by one of the sanitary officials and an offer to disinfect, free of cost, by the Sanitary Authority has been made, and in most cases carried out. ISOLATION HOSPITAL. The Hospital is built on a site of nine acres of land situated in Tottenhall Road, Palmers Green. It is a fine open and airy site, admirably adapted for the purpose. Only a portion of the site is at present occupied by the Hospital premises, the remainder being let off in allotments. The Hospital premises are entirely closed by a close boarded fence, and there is one entrance only, in Tottenhall Road. 34 The Hospital was opened in January, 1902, and consists (l) an administration block for the Staff; (2) a ward block; (3) an isolation block; (4) a laundry block with steam disinfecting apparatus and mortuary attached; and (5) an entrance lodge. The following amounts were sanctioned by the Local Government Board to be borrowed for the purpose of the Hospital:— (1) Purchase of land £2,500 (2) Fencing, draining, etc., of site, and building entrance lodge 1,600 (3) Erecting Hospital Buildings 8,400 (4) Furniture... 600 £13,100 The ward block is used entirely for Scarlet Fever cases, and consists of two wards, one 36ft. by 26ft. and 13ft. in height, for women and children, and the other 26ft. by 24ft. and 13ft. in height, for men, with a nurse's duty room between them, arranged so that the nurse-in-charge can look through a small fixed window into each ward. The male ward was designed to accommodate four beds and one cot, and the female ward six beds and one cot. But the air and floor space allowed was so ample that I find I can put up two extra beds or cots in each ward and still maintain sufficient air space. Lavatory and W.C. accommodation are provided at the ends of each ward, accessible from the ward only, but provided with a cross ventilation lobby. The wards are lighted and ventilated by large windows reaching to the ceiling on each side of the wards, and provided with fanlights which open inwards. Thorough cross ventilation is thus obtained. The wards are heated by special stoves in the centre of each, having downward flues carried under the floors to external chimney shafts attached to the building. The floors are of two kinds, that of one ward consisting of Terazzo, and the other of pitch-pine blocks. The walls are distempered with Duresco, with a dado of oil paint. There is also in this block a store cupboard for linen, bedding, etc., and a bath-room, arranged with a door leading outside, enabling it to be used as a discharging room. The bath is a portable one, and mounted on rubber wheels. 35 The nurses' duty room is fixed with a kitchen stove with hot water apparatus, a sink, small larder, large cupboard, kitchen dresser, medicine cupboard, and a telephone communicating with the administration block. The Isolation Block is used for Diphtheria and Typhoid Fever, and consists of two wards, or half a block ; the other half to be completed when more accommodation is required. Each ward is 24ft. by 18ft., and 13ft. in height, and accommodates three beds and a cot in each ward. A duty room similar to that of the ward block is provided between the wards. The sanitary accommodation is outside and separate from the block, but is under a verandah which runs along one side of the block. The doors of the wards and duty room open on to this verandah only. These wards are heated by open regenerating grates, and lighted and ventilated by windows similar to those of the ward block. All angles of walls, floors, ceilings, and woodwork in both blocks are constructed with rounded surfaces. The Administrative Block contains dispensary, Matron and Nurses' sitting room, store room, kitchen, scullery, coal store, and bedrooms for nine persons—the nursing staff and servants. The building is so designed that it can readily be enlarged to accommodate an increased staff. The Laundry Block is supplied with a high-pressure boiler, which supplies steam for boiling all water required in the Laundry. All steeping and washing of clothes is done in glazed stoneware troughs. A set of clothes-horses on runners are provided in a special chamber, heated with steam, for drying and airing clothes and linen when outdoor drying is unavailable. The same boiler also supplies steam for the steam disinfecting apparatus. Adjoining the Laundry is a Mortuary. The Entrance Lodge contains a parlour, kitchen-livingroom, with enclosed sick and bath, and one bedroom with usual accommodation, all under one roof and on the ground floor. The sanitary arrangements of the whole premises are perfect. Provision is made for thoroughly flushing all the foul water drains, and special ventilating shafts have been erected. All refuse is either burnt or disposed of on the enclosed area. The water supply passes through a meter on a bye-pass into a 4-in. main with 3-in. branches, and is provided with a 4-in. sluice valve which would be open to supply the three hydrants in case of fire. 36 The Medical and Nursing Staff consist of Medical Superintendent (non-sesident), Matron (nursing), two Staff Nurses, and one Probationer Nurse ; and the Domestic Staff of Cook, Wardmaid, Laundrymaid, Housemaid, and Entrance Lodge Porter and his wife. The Medical Superintendent's residence is connected with the Hospital by telephone. The Porter's duties consist of looking after the Entrance Lodge, checking all entries and exits, and working the steam disinfector, etc. His spare time is spent in the gardens. The Porter's wife assists, when required, in the Laundry, etc. Visitors are allowed to visit patients on Sundays from two to four o'clock, but are only allowed to communicate with the patients through the windows. If any patient is dangerously ill, special arrangements are made. The name of every person entering or leaving the premises, and the time of entry and exit, are entered in a book at the porter's lodge. Patients from outside districts are admitted when there is sufficient accommodation for them; the authorities of the Districts from which they come paying the Southgate Council for their maintenance. The cost of feeding staff and patients varies from l0d. to 1/3 per head per day. During the past year 132 cases were admitted ; of these, 62 were Scarlet Fever, 48 Typhoid Fever, and 22 Diphtheria. Two of the cases of Scarlet Fever were " return " cases. Eleven of the cases were admitted from outside the District; 8 of Scarlet Fever; 4 from Friern Barnet and 4 from Wood Green, and 2 of Diphtheria from Friern Barnet. There were 6 deaths—3 from Diphtheria, 2 from Typhoid Fever, and 1 from Scarlet Fever. The average times of detention in Hospital were:—For Scarlet Fever, 48 days; for Typhoid Fever, 38 days; and for Diphtheria, 33 days. The following table shows the average number of patients in Hospital for each month of the year, together with the smallest and greatest number in at one time in each month :— 37 Number of Patients in Isolation Hospital during each Month, 1906. Average number. Lowest number. Greatest number. Jan. 12 10 18 Feb. 14 13 17 Mar. 9 5 12 April 7 5 11 May 13 11 16 June 13 11 17 July 17 13 20 Aug. 15 12 18 Sept. 16 12 22 Oct. 24 20 29 Nov. 17 13 21 Dec. 14 13 15 Average for year 142 11.5 18 From the above table it will be seen that only during part of March and April was the minimum number of cases in Hospital less than 10, and that throughout the year the average number was somewhat high, whilst at times the Hospital was filled to its utmost capacity. The average was, it is true, raised by the exceptional number of cases of Typhoid Fever in Hospital during September, October, and November, due to the outbreak of Typhoid Fever in New Southgate; but apart from this there was still a relatively high average number of cases in Hospital as compared with previous years. This is not to be accounted for by the prevalence, above the average, of any particular infectious disease, but is due to an absolute average increase of cases of infectious disease in the district, on account of the constantly enlarging population which the Hospital has to serve. Although there is now a building available adjoining the Hospital site, which can be used as a temporary hospital at any time as an emergency, to accommodate any unusual number of infectious cases which might arise from some exceptional outbreak of infectious disease, yet, for general routine purposes, I am of opinion that, taking into consideration the rapidity with which the population of the District is increasing, it is very desirable that the Isolation Block should be completed by the addition of the other half as soon as possible. At the present time the two wards of this block have to accommodate both Diphtheria and Typhoid Fever, whereas for two separate diseases two wards each are required, one for male and one for female cases. 38 MISCELLANEOUS. Return of the Metropolitan Asylums Board.— During the past year 6,815 cases were admitted into this Hospital, situated at Winchmore Hill; of these 6,589 were Scarlet Fever, and 226 Diphtheria. There were 8 deaths from Scarlet Fever. Sewerage and Sewage Disposal.—The District is drained by the dual system. The surface water sewers discharge at convenient points into the nearest watercourses, and as the fields adjoining the smaller courses become converted into building land, suitable sewers and culverts are provided. Where possible and necessary the surface water sewers are laid at such depths as will enable the subsoil under cellars and basements to be drained and connected thereto, thus ensuring dry dwellings and avoiding any accumulations of stagnant water inside any dwelling-house. The main foul sewers traverse as much as possible the natural valleys, and run from the higher lands on the east towards the west, where they join up to the sewers of the Edmonton District at three points along the boundary between the Southgate and Edmonton Districts. At each of these points is a specially designed chamber, entirely constructed underground, for gauging the quantity of sewage that passes through. By the Edmonton Local Board Separation Act, 1881, by which Southgate became a separate District, the Edmonton District is required to receive, convey, and dispose of the sewage of Southgate, payment being made according to the quantity ascertained by a monthly system of gauging. After the separation from Edmonton it was found that the main sewers were in a very bad condition, and these have since been reconstructed upon the most improved principles. Only one length of sewer, apart from culverts, is now constructed of brickwork, that one being the southern main joining the Edmonton sewers. The sewers are laid principally in open trenches, but as their depth is in some cases as much as 25 feet below the surface, the driving of short tunnels as headings is occasionally resorted to. Pynmies Brook is crossed in several places by means of inverted syphons. These have been constructed with iron pipes from special designs, which permit the smallest area of sewage being exposed in the manholes, and have worked satisfactorily. The sewers are also carried at several points under the New River, and recently the late New River Company insisted upon a special system being 39 adopted, by which large cast-iron shield pipes are forced by means of powerful hydraulic jacks through the clay under the river, thus forming tunnels in which the sewer pipes are laid. In the case of new streets, not a pipe is permitted to he covered up until the work has been thoroughly inspected and the foul sewers tested with water. The pipes used have special joints, are made of the strongest stoneware clays, and laid upon a thick bed of cement concrete. In addition, they are laid to absolutely straight lines from point to point, and by means of manholes can be examined and seen through from end to end. At the head of every branch sewer means are provided by vertical shafts—lampholes and flushing chambers—through which thousands of gallons of clean water are systematically delivered in order to prevent any deposit within the sewers. There are upwards of 100 of these flushing chambers in the district. Fortunately, all the sewers in this district may be said to be self-cleansing, and within an hour or two of any foul matter being discharged into a drain or sewer it is delivered to the Edmonton Sewage Works. The sewers are ventilated by means of gratings over the manholes and by upcast shafts ; but the gratings intended to be inlets for fresh air sometimes also discharge foul air, in consequence of which many of them have been closed in, and extra upcast chafts erected at points of vantage in their place. During the past 15 years no drains of any house have been permitted to be connected to the sewers unless they have been provided with a chamber just within the boundary adjoining the street or road containing a trapped interceptor. Although the District is scattered over so large an area there are very few houses which are not near a sewer, so that fortunately very few cesspools now exist, and they are becoming less every year. In the District there are now 38¼ miles of foul sewers and 30½ miles of surface-water sewers, and no less than 25 miles of these have been constructed during the past 5 years. Sewers -During the past year a total of 10,942 yards of sewers were laid as follows:— New foul sewers ... ... 110 yards. New surface-water sewers ... 2,591 ,, New Estate Sewers. Foul sewers ... ... 3,748 ,, Surface-water sewers... ... 4,493 ,, 40 Water Supply.—Practically the whole District is now supplied by the Metropolitan Water Board, and very few houses are now dependent on wells for their water. Watercourses.—Bounds Green Brook and Pymmes Brook remain in about the same condition. The periodical cleaning by the Middlesex County Council helps to keep them from getting very foul, but they are still much polluted owing to the discharge into them of sewage effluents from neighbouring Districts. The attention of the Middlesex County Council has been frequently called to this matter, and as immediate action as possible should be taken by them in the interests of this District. House Refuse Collection.—Refuse and dust are collected from almost every house weekly and taken to one of the Council's shoots, the principal one being situated at Barrowell Green, the site of an old gravel pit. In consequence of the increase in the population of the District, this pit is being rapidly filled up; moreover, the refuse is accumulating there more rapidly than can be efficiently dealt with, and at times causes considerable nuisance from the stench arising therefrom, and is probably the cause of the swarms of flies which infest this particular neighbourhood. The number of houses, too, in the immediate neighbourhood, although not great at present, are increasing in number, which also makes the erection of a Dust Destructor continually more urgent; and I am glad to report that this matter is now receiving your practical attention. Collection of Fish Offal —Air-tight receptacles have been provided by the Council, in which fish offal is collected from the fish shops from once to three times a week, according to the weather and the amount of fish being consumed. It is then carted to a convenient shoot acquired by the Council for the purpose, and there dealt with. A small charge is made to the fishmongers to cover the expenses. Roads. -In the district there are now over 42 miles of Roads, made up as follows:— Miles. Yds. County Main Roads 4 1,356 Other Roads (Repairable by the inhabitants at large) 26 1,733 Private Roads (Repairable by the owners of property abutting on such Roads) 10 755 Total 42 324 41 The following roads were made up during the year : — York-road. Natal-road, Oak-road, Osborne-road, Howard-road, Eaton Park-road, Avondale-road, Devonshire-road. Broomfield-a venue. Station-avenue. Housing of the Working Classes Act, 1890. During the year 1 cottage in Highfield-road, Winchmore Hill, was closed; and 4 cottages in Firs-lane, Winchmore Hill, were closed and demolished. One cottage in Greenlanes, Palmers Green, was rendered fit for human habitation. There are many other old cottages remaining in different parts of the district which ought to be pulled down, and which would be condemned except for the fact that there are no better ones for the occupants to go into if this were done, which clearly shows the need there is in the district for the erection of sound healthy cottages at a reasonable rent. Such cottages as are from time to time demolished are at once replaced by villa and shop property, so that the necessity for providing suitable dwellings for the working classes becomes every year more urgent, and I trust that you will not lose sight of this important matter. As I have several times urged before, there is no more useful or necessary measure you could undertake. Public and Private Urinals.—There are no public conveniences in the District. An inspection was made of the whole of the sanitary conveniences attached to the various public-houses in the District, with the result that many urinals have been rebuilt and put in a better sanitary condition. The Council also provided improved lightings to a number of these urinals which are available for public use. Cowsheds, Dairies, Slaughter-houses, and Bakehouses. -These have been systematically inspected by the Sanitary Department, and have been kept in a satisfactory condition, in accordance with the Bye-laws. 42 Factory and Workshop Act, 1901.—The workshops in the district have been visited, and the sanitary condition, &c., noted in the register. The lists of outworkers have been received from the different Authorities, and the houses of such outworkers were visited and found in a satisfactory condition. 1. INSPECTION. Including Inspections made by Sanitary Inspectors or Inspectors of Nuisances. Premises. Number of Inspections. Written Notices. Prosecutions. Factories (Including Factory Laundries) 12 6 .. Workshops ( ,, Workshop Laundries) 68 18. .. Workplaces (Other than Outworkers' premises included in Part 8 of this Report) 28 7 .. Total 108 31 .. 43 2. DEFECTS FOUND. Particulars. Number of Defects. Number of Prosecutions. Found. Remedied. Referred to H.M. Inspector. Nuisances under the Public Health Acts:—* Want of Cleanliness 26 26 Want of Ventilation Overcrowding Want of Drainage of Floors 5 5 Other Nuisances 6 3 t Sanitary Accommodation— Insufficient Unsuitable or Defective 4 4 Not separate for sexes Offences under the Factory and Workshop Act :— Illegal occupation of Underground Bakehouse (s. 101) Breach of special sanitary requirements for bakehouses (ss. 97 to 100) Other Offences (Excluding offences relating to outwork which are included in Part 3 of this Report.) Total 41 41 * Including those specified in Sections 2, 3, 7, and 8, of the Factory and Workshop Act as remediable under the Public Health Acts. † Section 22 of the Public Health Acts Amendment Act, 1890, was adopted in 1890. 44 3. HOME WORK. Outworkers' List, Section 107. Nature of Work. Lists received from Employers once in the year. Numbers of Addresses of Outw'k's received from the Councils. Numbers of Addresses of Outw'k's. forwarded to other Councils. Number of Inspections of Outworkers' Premises. Lists. Outworkers. Wearing Apparal:— Making, &c. Nil. Nil. 11 Nil. 11 4. REGISTERED WORKSHOPS. Workshops on the Register (s. 131) at the end of the year (important classes of Workshops, such as Workshop Bakehouses) : — Workshops 50 Workshop Bakehouses 16 Homeworker's Premises 18 Total number of Workshops on Register 84 5. OTHER MATTERS. Class. NUMBER. Matters Notified to H.M. Inspectors of Factories :— Failure to affix Abstract of the Factor}- and Workshop Act (s. 133) Action taken in matters referred by H.M. Inspectors, as remediable under the Public Health Acts, but not under the Factory and Workshops Act (s. 5)- Notified Dy H.M. Inspectors 2 Reports (of Action taken) sent to H.M. Inspectors 2 Other Underground Bakehouses (s. 101) :— Certificates granted during the year In use at the end of the year COUNTY OF MIDDLESEX.—SANITARY WORK, 1906. Name of Sanitary Distiict:—SOUTHGATE. Inspections. Notices. Dwelling Houses. Houses Let in separate Dwellings or Lodgings. Common Lodging Houses. Canal Boats used as Dwellings. Movable Dwellings, Caravans, Tents, &c. Workshops and Work-places Number of Premises inspected on Complaint. Number of Premises Inspected in connection witb Infections Diseases. Number of Premises under Periodical Inspection. Houses Inspected from House-toll ouse. Total Number of Inspections and Re-inspeitioiis made. Cautionary Notices Given. .Statutory Orders Issued. Summonses Served. Convictions Obtained. Houses, Premises, &c., Cleansed, Repaired, &c., Closed as Unfit for Habitation. Re-opened after Repairs, Alterations,&c.,. Demolished. Illegal Underground Dwellings Vacated. Number Registered under Hyelaws Number of Contraventions. Number Registered under Hyelaws. Number of Contraventions. Nimber Registered under the Acts. Number of Contraventions of Regulations. Number Observed during the Year. Number of Nuisances therefrom abated. Number Removed from District. Number in District. Contraventions of Factory Acts. a b c d e 98 197 127 245 3026 119 36 Nil. Nil. 131 1 1 4 Nil. Nil. Nil. Nil. Nil. Nil. Nil. 14<i Nil. 146 60 Nil. COUNTY OF MIDDLESEX—SANITARY WORK, 1906. Name of Sanitary District:-SOUTHGATE. Laundries. Bakehouses. Slaughterhouses. Cow-sheds. Dairies and Milk-shops. j Unsound Food. Alu'terated Food. Offensive Trades Water Supply and Water Service. Wells. Percentage of Houses supplied from Public Water Service. Cisterns. Draw-Taps removed from Cisterns to M ains. Percentage of Houses supplied on Constant System. Number in District. Contraventions of Factory Acts. Number in District. Contraventions of Factory Acts. Number 011 Register. Contravention* of Byelawg. Number on Register. Contraventions of Regulations. Number on Register. Contraventions of Regulations. Animals seized. Articles or Parcels seized. Articles or Parcels surrendered. Samples taken. Found Adulterated. Number of Premises in District. Contraventions of Byelaws. New Sunk. Cleansed, Repaired, &c. Closed as Polluted. New, Provided. Cleansed, Repaired, Covered, &c. Overflow Pipes Disconnected from Mains. 8 Nil. 16 Nil. 8 Nil. 10 Nil. 17 1 Nil. Nil. Seven Boxes of Fish. Nil. Nil. Nil. Nil. Nil. 2 Nil. Practically the whole. 1 11 Nil. 9 90% COUNTY OF MIDDLESEX.—SANITARY WORK, 1906. Name of Sanitary District:—SOUTHGATE. Drainage and Sewerage. Disinfection. Dust. Sundry Nuisances Abated. Water Closets. Drains. Cesspools. New Constructed. Number of Water Closets substituted forDry Receptacles. Repaired, Supplied with Water, or otherwise Improved. Percentage of Houses provided with Water closets. Kxamined, Tested, Exposed, &c. Unstopped, Repaired, Trapped, &c. Waste Pipes, Rain Water Pipes Disconnected, Repaired &c. Soil Pipes and Drains Ventilated. Disconnecting Traps or Chambers Inserted. Reconstructed. Rendered Impervious, Emptied, Cleansed, &c. Abolished, and Drain connected to Sewer. Percentage of Houses Draining into Hewers. Rooms Disinfected. Rooms Stripped and Cleansed. Articles Disinfected or Destroyed. New Bins provided. Periodical Frequency of Dust Removal. N umber of Complaints of N on-Removal received. Overcrowding. Smoke. Accumulations of Refuse. Foul Ditches. Ponds, «Ve., and Stagnant Water. Foul Pigs and other Animals. Dampness. Other Nuisances. 1 Nil. 116 Practically the whole. 92 35 26 53 48 65 1 Nil. 99 % 225 173 1236 38 Weekly. 27 3 7 8 6 4 5 53 J. W. H, BROWN, Sanitary Inspector,