Rushden Research Group: Health - Sanatorium - Mass Miniature Radiography 1945-46

Extracted from the files of Rowan Flack
Former Chief Nursing Officer, Rushden Hospital
Transcribed by Greville Watson, 2008

Northamptonshire

Mass Miniature Radiography 1945-46

Occupational incidence of acute phthisis as shown by first survey of industrial centres in county
By C M Smith MD DPH County Medical Officer of Health

1. This report covers the period from 1^st March, 1945, when the Unit began work at the County Hall, Northampton, until the completion of the survey in Wellingborough on 30^th May, 1946. During this period the surveys carried out by the Unit were as follows:

	Period of Survey	No. of persons examined	Percentage examined
Preliminary Survey
(County Hall, Northampton)	March, 1945	1,054	--
Rushden	April, May, 1945	5,119	84
Kettering	June - October, 1945	9,806	81
Northampton	Oct., 1945 - March, 1946	14,544	70
Wellingborough	March - May, 1946	8,109	77

	Total	38,632

The percentage response is the percentage of persons who accepted invitations to be examined. The preliminary survey included members and staffs of the Northamptonshire County Council and Northampton Corporation, and also the staff of Berrywood Mental Hospital and of one factory outside the County Borough. The other surveys were restricted almost entirely to the examination of factory employees.

2. The opportunity is thus present to submit a report giving a comparison of the findings in the various occupations in the main industrial areas of the geographical County excluding Corby. Since the boot and shoe trade is the staple industry, the incidence of active tuberculosis in the industry has been compared with all other occupations followed by the workpeople examined. The total number of persons examined in all the surveys was 38,632, of whom 17,436 were employed in the boot and shoe industry and 21,196 in other occupations.

Previous Reports

3. It is not inopportune to refer to the report issued in 1915 by the Special Investigation Committee upon the Incidence of Phthisis in Relation to Occupations. The first report of the Committee dealt with the boot and shoe industry and was published by the Medical Research Committee. The summary of the conclusions was as follows:

“ (i)	Phthisis is specially prevalent among workers in the boot and shoe industry, as compared with the general population.
(ii)	The individual worker is predisposed to infection by the sedentary nature of his employment, and possibly by the attitude he adopts at works.
(iii)	The infection is probably
		(a)	Increased by the number of infective workers, and
		(b)	Favoured by want of light, the presence of infected dust, and inadequate ventilation in the work‑rooms.”

Reference should also be made to the Registrar-General’s Decennial Supplement England and Wales, 1931, on Occupational Mortality. As regards the boot and shoe trade, two main groups are dealt with in this report: group 36 Boot and Shoe Makers (Hand‑workers) and Repairers, Census population (males) 49,998; and group 37 Boot and Shoe, etc., Workers and Factory Operators, Census population (males) 45,038. Taking the occupational mortality at ages 2065 from tuberculosis of the lungs of all occupied males as 100, the occupational mortality for group 36 is shown as 131, and for group 37 as 188. In the report, 86 occupations are put in order as regards respiratory tuberculosis mortality, occupations with the highest rates being placed at the bottom of the list. In the table showing ranking of the 86 occupations, group 36 occupied 70^th position and group 37 ranked 81^st.

For purposes of comparison, occupations with a higher respiratory tuberculosis mortality rate were as follows:

		Registered Deaths per 100
Group		Standard at years 20 - 65
66.	Costermongers, Newspaper-sellers	200
78.	Barmen	212
26.	Glaziers, Polishers, Buffers, Moppers	230
14.	Potters, Ware-makers, Casters, Finishers	233
25.	Grinders	275

4. Method of Presenting Results.

In this report newly-discovered active tuberculosis of the lungs in persons who require to stay off work for treatment, either at home or in Sanatoria, is dealt with. Previously known cases of tuberculosis and observation cases have all been excluded.

In order that expert statistical help should be afforded, I consulted Dr Percy Stocks, Medical Statistician, General Register Office and Ministry of Health, who advised on the layout of the statistical tables and made the necessary calculations to determine whether the differences found were statistically significant.

5. The Results of the Survey

Table I.

Northamptonshire Mass Radiography Survey, 194546.

Rushden, Kettering, Northampton and Wellingborough Areas.

Analysis by Occupation,* Age and Sex of newly-discovered cases of Active Pulmonary Tuberculosis in persons who required to stay off work for treatment, either Sanatorium or Domiciliary.

Column:
(1)        Occupation
(2)        Sex
(3)        Number Examined
(4)        Number of Active P.T. Cases
(5)        Rate per 1,000
(6)        Number Examined
(7)        Number of Active P.T. Cases
(8)        Rate per 1,000
(9)        Expected Number of Active P.T. Cases at rates for occupations other than Boot and Shoe
(10)      Actual Number of Active P.T. Cases
(11)      Excess ± Standard Error
(12)      Is difference significant?

	* See Footnote		14 to 34 Years			35+ Years			All Ages

(1)		(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	(10)	(11)	(12)

A.	Boot and Shoe	M.	1,756	10	5.69	7,775	46	5.92	21.86	56	34.1 ± 4.7	Yes
		F.	4,457	41	9.20	3,448	5	1.45	34.85	46	11.1 ± 5.9	Doubtful
		P.	6,213	51		11,223	51		56.71	102	45.3 ± 7.5	Yes

B.	Engineering	M.	1,662	2	1.20	2,062	5	2.42	7.23	7	-0.2 ± 2.7	No excess
		F.	1,086	10	9.21	164	--	--	7.68	10	2.3 ± 2.8	No
		P.	2,748	12	--	2,226	5	--	14.91	17	2.1 ± 3.9	No

C.	Clothing	M.	149	--	--	280	--	--	0.89	--	-0.9 ± 0.9	No excess
		F.	2,044	19	9.30	714	1	1.40	14.94	20	5.1 ± 3.9	No
		P.	2,193	19	--	994	1	--	15.83	20	4.2 ± 4.0	No

D.	Public Administration (including Civil Service and Local Government Officers, Clerical Staff, Police, Roadmen and other workmen)	M.	249	1	4.02	1,109	4	3.61	3.12	5	1.9 ± 1.8	No
		F.	456	1	2.19	285	--	--	3.48	1	-2.5 ± 1.9	No excess
		P.	705	2	--	1,394	4	--	6.60	6	-0.6 ± 2.6	No excess

E.	Transport and Communication (G.P.O., L.M.S. and Transport Lorry Drivers)	M.	528	--	--	982	1	1.02	3.13	1	-2.1 ± 1.8	No excess
		F.	333	3	9.01	103	1	9.71	2.42	4	1.6 ± 1.6	No
		P.	861	3	--	1,085	2	--	5.55	5	-0.5 ± 2.4	No excess

F.	Clerical Workers (Factory and Business Offices)	M.	231	--	--	276	--	--	0.98	--	-1.0 ± 1.0	No excess
		F.	1,113	3	2.70	206	--	--	7.92	3	-4.9 ± 2.8	No excess
		P.	1,344	3	--	482	--	--	8.90	3	-5.9 ± 3.0	No excess

G.	Leather Dressing	M.	249	--	--	1,003	3	2.99	2.85	3	0.1 ± 1.7	No
		F.	236	1	4.24	151	--	--	1.81	1	-0.8 ± 1.3	No excess
		P.	485	1	--	1,154	3	--	4.66	4	-0.7 ± 2.2	No excess

H.	Workers in Wood, Upholsterers, etc. (Carpenters, Last-makers, Upholsterers, Coachbuilders, Painters)	M.	269	1	3.72	399	2	5.01	1.34	3	1.7 ± 1.2	No
		F.	48	--	--	15	1	66.07	0.35	1	0.6 ± 0.6	No
		P.	317	1	--	414	3	--	1.69	4	2.3 ± 1.3	No

I.	Makers of Food and Drink (Cereal-makers, Pie Factories, Brewers)	M.	134	--	--	317	3	9.46	0.97	3	2.0 ± 1.0	No
		F.	139	--	--	62	--	--	1.03	--	-1.0 ± 1.0	No excess
		P.	273	--	--	379	3	--	2.00	3	1.0 ± 1.4	No

J.	Professional Occupations (Nurses, Teachers)	M.	14	--	--	78	--	--	0.21	--	-0.2 ± 0.5	No excess
		F.	194	--	--	236	--	--	1.62	--	-1.6 ± 1.3	No excess
		P.	208	--	--	314	--	--	1.83	--	-1.8 ± 1.4	No excess

K.	Foundry Workers	M.	138	--	--	351	--	--	1.06	--	-1.1 ± 1.0	No excess
		F.	--	--	--	--	--	--	--	--
		P.	138	--	--	351	--	--	1.06	--	-1.1 ± 1.0	No excess

L.	Warehouse and Storekeepers (Warehousemen, Storekeepers, Packers, Caretakers)	M.	92	--	--	238	--	--	0.71	--	-0.7 ± 0.8	No excess
		F.	68	3	44.12	50	--	--	0.53	3	2.5 ± 0.7	Doubtful
		P.	160	3	--	288	--	--	1.24	3	1.8 ± 1.1	No

M.	Other Occupations (Agricultural Workers, Gas Co. Chemical Products, Boxmakers, Printers, Rubber & Plastics, Shop Staff, Personal Service, Stationary Engine Drivers, Flax Mills, Berrywood, Tilemakers, Antenatal, Housewives, etc.)	M.	443	1	2.26	772	2	2.59	2.49	3	0.5 ± 1.6	No
		F.	964	6	6.22	504	--	--	7.25	6	-1.2 ± 2.7	No excess
		P.	1,407	7	--	1,276	2	--	9.74	9	-0.7 ± 3.1	No excess

N.	All Occupations except Boot and Shoe	M.	4,158	5	1.20	7,867	20	2.54	25	25	--
		F.	6,681	46	6.89	2,490	3	1.20	49	49	--
		P.	10,839	51	--	10,357	23	--	74	74	--

O.	All Occupations including Boot and Shoe	M.	5,914	15	2.54	15,642	66	4.22	46.86	81	34.1
		F.	11,138	87	7.81	5,938	8	1.35	83.85	95	11.1
		P.	17,052	102	--	21,580	74	--	130.71	176	45.3

* The Occupational Analysis has not been carried out strictly in accordance with the instructions of the Ministry of Health. In the Boot and Shoe Industry all persons engaged in the industry have been shown in this group, instead of, for example, classifying clerks under Clerical and warehouse workers under Warehousemen.

Further, Public Administration includes all the various groups employed either in the Civil Service or Local Government Services, varying in social class from Administrative and Executive, Class 2, to unskilled labours, Class 5. Again, in Transport and Communication, clerks were included in this group, instead of being shown under the correct category. In all remaining occupations listed in the table, the Ministry’s instructions in regard to classification of occupations have been followed.

It should be explained that the preparation of this report has been carried out under some difficulty, because no separate clerk was appointed for the statistical work which has involved dealing with over thirty-eight thousand cards by manual methods, and the work has been done by one of the clerical staff of the Unit, who have been consistently working under pressure to keep abreast of routine duties.

In any event, the effect of including all workers in the Boot and Shoe Trade that is, Management, Office Staff, Warehousemen and so on is to make the ascertained rates in the industry possibly less than they would otherwise be, for the incidence of active tubercle in the Management and Clerical Staff, etc., is probably less than among the operatives.

	The areas surveyed were as follows:

	Rushden Area	Total number examined 5,119. The County Districts surveyed were Rushden Urban District and Higham Ferrers Borough.

	Kettering Area	Total number examined 9,806. The County Districts surveyed were Kettering Borough (7,331), Burton Latimer Urban (855), Desborough Urban (1,068) and Rothwell Urban (552).

	Northampton Area	In the preliminary survey in the County Hall, 1,054 were examined. In the main survey, 13,412 were examined; in addition, 1,132 working in factories outside the Borough boundary were included.

	Wellingborough Area	Total number examined 8,109. The County Districts surveyed were Wellingborough Urban District (5,646), Wellingborough Rural District (1,265) and Irthlingborough Urban District (1,198).

6. The above table may appear formidable, but it is necessary to present the figures in the manner shown in order to make allowances for differences in age and sex. Two main age groups have been taken, viz. 1434 years and 35+ years. As is well recognized, tuberculosis of the lungs is generally more prevalent among young people, and there is also a greater tendency for young females to suffer from the disease. In comparing one occupation, or one area with another, due allowance must accordingly be made for differences in age and sex constitution.

7. In Column 10 of the Table it will be seen that in the boot and shoe trade, taking both age groups and both sexes, 102 cases of newly-discovered active pulmonary tuberculosis in persons who required to stay off work for treatment were discovered. Throughout this Report these cases are referred to as active tuberculosis cases. The number of cases that would be expected had the boot and shoe employees experienced the same rates as all other workpeople in the areas surveyed, excluding the boot and shoe trade, is 56.71; this figure is entered in Column 9. The difference between the number of cases actually found and the expected number is shown in Column 11 to be 45.3, and the last column shows that the difference is statistically significant, i.e. the difference is more than would be found by errors of chance sampling. When the sexes are considered separately, it will be observed from the table that, in the case of males, there is a statistically significant difference between the expected number of active tuberculosis cases and the actual number; the expected number (Column 9) was 21.86 and the actual number was 56 (Column 10). In the case of females, the expected number was 34.85 and the actual number was 46; the difference is doubtful statistical significance, for the excess (11.1) is not quite twice the standard error (5.9). The considerable difference between the expected and the actual number of active tuberculosis cases among males is noteworthy.

8. The former Medical Director has informed me that he was struck by the number of men, middle-aged or older, who were found with comparatively slight symptoms but nevertheless were harbouring tubercle bacilli in the sputum and were consequently a source of infection. It will be noted that among men under 35 years in the boot and shoe trade, the rate per 1,000 of active tuberculosis cases is 5.69 (Column 5) compared with 1.20 per 1,000 among men of similar age in all other occupations. For men of 35+ years, the corresponding rates were 5.92 per 1,000 (Column 8) and 2.54 per 1,000. For women under 35, the rate for the boot and shoe trade was 9.20 per 1,000 (Column 5) compared with 6.89 per 1,000 in other occupations, and in the 35+ group the rates were 1.45 per 1,000 (Column 8) and 1.20 per 1,000 respectively. In men the higher rates were found in the older age groups as well as in the younger. Of 46 active tuberculosis cases among men 35+ years in the boot and shoe trade, no less than 21 were found to have positive sputum. The removal of these men as sources of infection from the factories represents an effective step to prevent further infection.

9. The table also reveals that active tuberculosis cases among the remaining occupations included in the survey, viz. Engineering, Clothing, Leather Dressing, etc., showed no significant difference between the expected and the actual number of cases.

The incidence of active tuberculosis cases in the boot and shoe trade for all the areas surveyed was 5.85 per 1,000 (102 cases among 17,436 persons), compared with 3.49 in all occupations excluding the boot and shoe trade (74 cases among 21,196 persons). The incidence of active tuberculosis cases for all occupations in all areas surveyed is 4.56 per 1,000 (176 cases among 38,632 persons).

10. Departmental Analysis of the Boot and Shoe Trade.

Having ascertained that, allowing for differences of age and sex, the incidence at the time of the survey of active tuberculosis cases was significantly higher in the boot and shoe trade as compared with other occupations, the next question to be answered is Can any difference be detected in the various departments of the Industry? These have been taken as follows:

	Clicking.	Cutting upper leather into components.

	Closing.	Sewing component parts together to make complete upper.

	Rough Stuff.	Cutting out the inner and outer soles and stiffeners to make complete bottom.

	Lasting.	Attaching bottom to the upper.

	Finishing.	Trimming heels and edges and polishing heels and edges.

	Shoe Room.	Shoe cleaned and polished, and boxed ready for despatch.

Table II.

Northamptonshire Mass Radiography Survey, 194546.

Rushden, Kettering, Northampton and Wellingborough Areas.

Boot and Shoe Industry Analysis by departments of newly-discovered cases of Active Pulmonary Tuberculosis in persons who required to stay off work for treatment, either Sanatorium or Domiciliary.

		14 - 34 Years			35+ Years			All Ages

(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	(10)	(11)	(12)

Clicking	M.	447	4	8.95	1,417	8	5.65	4.14	12	7.9 ± 2.0	Yes
	F.	91	--	--	63	--	--	0.70	--	-0.7 ± 0.8	No excess
	P.	538	4	--	1,480	8	--	4.84	12	7.2 ± 2.2	Yes

Closing	M.	13	--	--	28	1	35.71	0.09	1	0.9 ± 0.3	No
	F.	2,530	22	8.70	2,077	2	0.96	19.92	24	4.1 ± 4.5	No
	P.	2,543	22	--	2,105	3	--	20.01	25	5.0 ± 4.5	No

Rough Stuff	M.	144	1	6.94	880	2	2.27	2.41	3	0.6 ± 1.6	No
	F.	208	--	--	258	--	--	1.74	--	-1.7 ± 1.3	No excess
	P.	352	1	--	1,139	2	--	4.15	3	-1.1 ± 2.0	No excess

Lasting	M.	664	2	3.01	2,618	18	6.88	7.45	20	12.5 ± 2.7	Yes
	F.	189	4	21.16	179	1	5.59	1.52	5	3.5 ± 1.2	Yes
	P.	853	6	--	2,797	19	--	8.97	25	16.0 ± 3.0	Yes

Finishing	M.	260	3	11.54	1,612	12	7.44	4.41	15	10.6 ± 2.1	Yes
	F.	47	--	--	37	--	--	0.37	--	-0.4 ± 0.6	No excess
	P.	307	3	--	1,649	12	--	4.78	15	10.2 ± 2.2	Yes

Shoe Room	M.	14	--	--	187	1	5.35	0.45	1	0.5 ± 0.7	No
	F.	455	7	15.38	406	--	--	3.62	7	3.4 ± 1.9	No
	P.	469	7	--	593	1	--	4.11	8	3.9 ± 2.0	No

Miscellaneous Boot and Shoe	M.	215	--	--	1,033	4	3.87	2.88	4	1.1 ± 1.7	No
	F.	936	8	8.55	427	2	4.68	6.96	10	3.0 ± 2.6	No
	P.	1,151	8	--	1,460	6	--	9.84	14	4.2 ± 3.1	No

Note
Miscellaneous Boot and Shoe group includes everyone engaged in the work of a Boot and Shoe factory, other than in the six particular columns above, i.e. administrative staff, warehouse workers, a smaller number of heel builders and stiffener makers, reclaiming department, etc.

Table III.

Northamptonshire Mass Radiography Survey, 194546.

Rushden, Kettering, Northampton and Wellingborough Areas.

Analysis by area of newly-discovered cases of Active Pulmonary Tuberculosis in persons who required to stay off work for treatment, either Sanatorium or Domiciliary.

Column:
(1)        Occupation
(2)        Sex
(3)        Number Examined
(4)        Number of Active P.T. Cases
(5)        Rate per 1,000
(6)        Number Examined
(7)        Number of Active P.T. Cases
(8)        Rate per 1,000
(9)        Expected Number of Active P.T. Cases at rates for occupations other than Boot and Shoe in all areas combined
(10)      Actual Number of Active P.T. Cases
(11)      Excess ± Standard Error
(12)      Is difference significant?

			14 - 34 Years			35+ Years			All Ages

	(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	(10)	(11)	(12)

Rushden Area	1. Boot and Shoe	M.	267	3	11.24	1,943	11	5.66	5.26	14	8.7 ± 2.3	Yes
		F.	776	8	10.31	854	--	--	6.37	8	1.6 ± 2.5	No
		P.	1,043	11	--	2,797	11	--	11.63	22	10.4 ± 3.4	Yes

	2. Other Occupations	M.	149	--	--	462	2	4.33	1.35	2	0.6 ± 1.2	No
		F.	521	5	9.60	147	--	--	3.77	5	1.2 ± 1.9	No
		P.	670	5	--	609	2	--	5.12	7	1.9 ± 2.3	No

	3. Both	M.	416	3	7.21	2,405	13	5.40	6.61	16	9.4
		F.	1,297	13	10.02	1,001	--	--	10.14	13	2.9
		P.	1,713	16	--	3,406	13	--	16.75	29	12.2

Kettering Area	1. Boot and Shoe	M.	398	4	10.05	1,942	13	6.69	5.41	17	11.6 ± 2.3	Yes
		F.	1,048	7	6.68	899	2	2.22	8.30	9	0.7 ± 2.9	No
		P.	1,446	11	--	2,841	15	--	13.71	26	12.3 ± 3.7	Yes

	2. Other Occupations	M.	803	--	--	1,851	4	2.16	5.67	4	-1.7 ± 2.4	No excess
		F.	2,044	11	5.38	821	--	--	15.07	11	-4.1 ± 3.9	No excess
		P.	2,847	11	--	2,672	4	--	20.74	15	-5.7 ± 4.6	No excess

	3. Both	M.	1,201	4	3.33	3,793	17	4.48	11.08	21	9.9
		F.	3,092	18	5.82	1,720	2	1.16	23.37	20	-3.4
		P.	4,293	22	--	5,513	19	--	34.45	41	6.5

Northampton Area	1. Boot and Shoe	M.	755	3	3.97	2,769	20	7.22	7.94	23	15.1 ± 2.8	Yes
		F.	2,003	20	9.99	1,125	3	2.67	15.15	23	7.8 ± 3.9	Yes
		P.	2,758	23	--	3,894	23	--	23.09	46	22.9 ± 4.8	Yes

	2. Other Occupations	M.	1,853	4	2.16	3,402	10	2.94	10.86	14	3.1 ± 3.3	No
		F.	2,694	18	6.68	997	1	1.00	19.76	19	-0.8 ± 4.4	No excess
		P.	4,547	22	--	4,399	11	--	30.62	33	2.4 ± 5.5	No

	3. Both	M.	2,608	7	2.68	6,171	30	4.86	18.80	37	18.2
		F.	46,978	38	8.09	2,122	4	1.89	34.91	42	7.1
		P.	7,305	45	--	8,293	34	--	53.71	79	15.3

Wellingborough Area	1. Boot and Shoe	M.	336	--	--	1,121	2	1.78	3.00	2	-1.0 ± 1.7	No excess
		F.	630	6	9.52	570	--	--	5.02	6	1.0 ± 2.2	No
		P.	966	6	--	1,691	2	--	8.02	8	0	No excess

	2. Other Occupations	M.	1,348	1	0.74	2,152	4	1.86	7.08	5	-2.1 ± 2.7	No excess
		F.	1,427	12	8.41	525	2	3.81	10.46	14	3.5 ± 3.2	No
		P.	2,775	13	--	2,677	6	--	17.54	19	1.5 ± 4.2	No

	3. Both	M.	1,684	1	0.59	3,273	6	1.83	10.33	7	-3.3
		F.	2,057	18	8.75	1,095	2	1.83	15.49	20	4.5
		P.	3,741	19	--	4,368	8	--	25.82	27	1.2

It will be noted that the number of cases found in the Clicking, Lasting and Finishing Departments is greater than the expected number. Among 1,864 clickers (men) examined, the expected number of active tuberculosis cases was 4.14, but the number actually found was 12. Among the 3,282 men in the Lasting Department, the expected number of active tuberculosis cases was 7.45 and the actual number was 20, and among 1,872 men in the Finishing Department, the expected number was 4.41 and the actual number was 15. All these differences are statistically significant. The table shows that there was an excess incidence in the Clicking, Lasting and Finishing Departments, i.e. that more active tuberculosis cases were discovered than would have been found had the employees experienced the rates ascertained in all occupations other than the boot and shoe industry in all areas.

11. Geographical Comparison

Table III. shows analyses by areas of the incidence of active tuberculosis cases. The table also includes a comparison of the boot and shoe trade withal other occupations. As would be expected from the findings previously discussed in Table I, the table reveals that there is a statistically significant excess in the boot and shoe trade in Rushden (males only), Kettering (males only) and Northampton (both sexes), but in the Wellingborough area, where the number surveyed in the industry was only 2,677, no excess was found. As regards female workers in the boot and shoe trade, the table shows a significant excess in the Northampton area only, where the expected number of active tuberculosis cases was 15.15 and the actual number was 23. The important point to be noted is that so far as occupations other than the boot and shoe trade are concerned, there is no excess in any of the four areas.

For purposes of interest, the summary of the findings in the four areas is as follows:

Area.	Number Surveyed.	No. of Active Tuberculosis Cases.	Rate per 1,000.
Rushden	5,119	29	5.67
Kettering	9,806	41	4.18
Northampton	15,598	79	5.06
Wellingborough	8,109	27	3.33

A table such as the above is, however, misleading, since it takes no account of factors which, as previously explained, will materially affect the comparison, these factors being differences in the age and sex constitution and in the proportion of people employed in the boot and shoe trade in each area.

12. Comparison with other Surveys.

The following table affords a comparison of the Northamptonshire survey with other surveys.

			*No. examined.*	No. of Active Tuberculosis Cases per 1,000.
London County Council (Note 1)			46,671	3.1
Birmingham (Note 2)			13,700	3.6
Glasgow (Note 3)			30,652	5.9
Medical Research Council Report (Note 4)
	--Office Staff		10,103	4.0
		Factory A.	4,720	3.0
		Factory B.	5.657	4.0
Northamptonshire			38,632	4.4
"		(Boot and Shoe)	17,436	5.7
"		(Other Occupations)	21,196	3.25

Notes:

		1.	Interim Report of County Medical Officer of Health of London County Council for 1944, page 26.
		2.	British Medical Journal, 29^th December, 1945, page 932.
		3.	Résumé of work of Public Health Dept. (Glasgow), 1945.
		4.	Medical Research Council Report (Special Report Series No. 251, 1945).

Replying to a Parliamentary question on 25^th July, 1946, the Minister of Health stated that in England and Wales up to 31^st December, 1945, approximately 797,000 civilians had been examined by Mass Radiography, of whom 2,900 were diagnosed as suffering from active tuberculosis. This represents 3.6 per 1,000. It will be observed that, excluding Glasgow, the rate for the geographical County is somewhat higher than the rates found in other surveys or in England and Wales, as revealed in the Parliamentary answer.

13. Discussion.

The incidence of active tuberculosis discovered in the Boot and Shoe Trade can be fully assessed only when, as a result of Mass Radiography surveys in other parts of the country, the prevalence of the disease in other occupations is determined, in order that accurate comparisons can be made.

One point must be emphasized namely, the boot and shoe industry was not a reserved occupation during the War, so that no doubt the results are affected by all the fit men of military age having been called to national service. A similar survey, carried out some years hence, might reveal different results. Whether the fact of the occupation not being reserved is sufficient to account for the excess rates, is a matter on which sufficient information is not available to express an opinion.

The report referred to in Item 3 stated that the infection is probably increased by the number of infective workers. In my opinion, the results of the survey leave no doubt on this question. The same report also stated that infection is probably increased by want of light and inadequate ventilation in the workroom. A comparison of factory conditions, as regards light and ventilation, in the boot and shoe industry with other occupations, would require to be made before this statement could be substantiated.

The Working Party Report on the Boot and Shoe Industry, 1946, presented to the President of the Board of Trade, contains summary reports by H.M. Inspectors of Factories. The summary includes the following:

“ Conditions in the boot and shoe industry are well described by an Inspector who has had long experience of the trade as of a ‘good medium standard,’ but, like other old‑established industries, it is not up‑to‑date in welfare matters. The work is not especially dirty, unpleasant or heavy, though some of the processes call for concentrated effort, and it is not considered a black spot amongst industry generally.

“ Overcrowding. In the legal sense a workroom is ‘overcrowded’ if less than 400 cubic feet of space of space is provided for each person employed therein. There is very little overcrowding in this sense, but there is considerable congestion in many shops due to the use of boot racks. A conveyor system has been tried in some factories, but it is said not to be successful except where a standard type of shoe is made. The tendency to crowd as many workers and machines as possible into small rooms is commented on.

“ Ventilation. Means of general ventilation provided are generally adequate except in some large area single-storey premises, but are often not well used. Dust extraction plant is of a good standard and well maintained.

“ Categories. Factories were classified as (a) good premises, (b) buildings substantial in nature, but requiring considerable internal alternation to enable the provisions of the Factories Act to be carried out, and (c) old and dilapidated, requiring to be demolished.” A table classifying the factories showed that the industry is handicapped by old‑fashioned buildings, and that in general the larger the factory the better it is housed.”

H.M. Medical Inspector of Factories’ report contained the following statement:

“ For efficient and healthful working, space not only for the worker but for the machine is a clamant desideratum, but there appeared to me to be a tendency to crowd as many workers and machines as possible into small rooms which only too often were ill‑ventilated, and where, when the means of ventilation were available, the workers, rather than take advantage of them, preferred to immure themselves in a hot air bath. Clickers with whom I have spoken abhor a draught as nature abhors a vacuum. Most of them think, in the colder season at least, that it is unnatural to work with open windows at their trade. In the smaller factories visited, I observed only two instances of the windows being open during work. This should not be, for the clicker is denied the free air movement in his workroom which is allowed his fellow workers who carry out their jobs among machinery, where moving belts and pulleys help to prevent air stagnation.”

Similarly, as to whether the individual worker is predisposed to infection by the sedentary nature of his employment, and the attitude he adopts, is a question on which insufficient facts are available to express an opinion a comparison would require to be made with other sedentary occupations. Other possible factors to be reviewed are (a) selective recruitment; many branches of the work can be followed by men who are not robust; (b) injurious dust particles; but as far as is known there is no evidence of a dust factor, such as silica, which causes a high rate in the pottery trade, and (c) economic factors, namely, the level of wages over the last two or three decades in comparison with other occupations in the industrial parts of the county; on this subject a careful economic review would be needed.

Further discussion would be unprofitable for the necessary data are not available to me.

14. Summary.

The findings of the first Mass Radiography Survey in the main industrial centres of the geographical County reveal that, compared with all other occupations, there is a statistically significant excess of newly-discovered cases of active pulmonary tuberculosis in the boot and shoe industry; and further, that there are significantly higher rates in the clicking, lasting and finishing departments of the industry.

15. Recommendation.

I advise that copies of this report should be sent to the Ministry of Health, the Ministry of Labour, the Northampton County Borough, and to the Organizations representing the employers and employees of the boot and shoe trade, and that the suggestion be made to the above‑named bodies that, together with the County Council, representatives be appointed to give further consideration to the findings contained in this report, and in particular to advise on what action, if any, can be taken to reduce the incidence of tuberculosis in the boot and shoe industry.

16. Acknowledgements.

I have great pleasure in thanking Dr. Percy Stocks for his expert assistance on the statistical aspects of the report. Thanks are also due to Dr. M. C. Brough, the former Medical Director of the Unit, and to Miss M. J. Williams, who has been responsible for the records. Dr. G. B. Lord and Dr. N. B. Laughton, the Clinical Tuberculosis Officers for the County and Borough respectively, have also kindly supplied information regarding the results of their investigations of the cases referred to them by the Unit.

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