26i

SOCIAL AND ENVIRONMENTAL FACTORSIN CHRONIC BRONCHITIS

IN NEWCASTLE UPON TYNEA. G. OGILVIE, M.D., F.R.C.P.

Royal Victoria Infirmary, Newcastle upon Tyne

The study of social habits and conditions, andof environment in relation to disease, is time-consuming, and progress is slow.

Despite much work, a great deal remains to belearned regarding the natural history of chronicbronchitis, and the effect upon it of the conditionsof life and work. The greater part of the work inthis field has been carried out from the Pneumo-coniosis Research Unit of the Medical ResearchCouncil in South Wales, from the University ofSheffield, and from the Postgraduate MedicalSchool of London.

This work will be referred to in the followingdiscussion, but the main intention is to considerthe disease as it affects Newcastle, and in the lightof information gleaned in a survey of the citywhich was carried out in 1955-56.'2 At that timethe basic problem of the clinical recognition ofthe disease had hardly been considered, much lesssolved, and it will readily be appreciated that inany such survey diagnosis is crucial.The advanced case may readily be recognized,

but the main object of such environmental studyis lost unless all cases, the early and mild, as well asthe advanced, are included. Symptoms are all wehave in the early stage of bronchitis, and thedisease is usually gradual in onset. Nevertheless,a point must be recognized at which we are tosay that the disease exists-and the followingdefinition was set up. ' . . . chronic bronchitis isrecognized as a long-standing condition, theessential features of which are cough with sputum,persistent throughout the winter or throughoutthe year, in the absence of other causative respira-tory disease. A minimum duration of two years isessential for its recognition'. The diagnosis ofchronic bronchitis during the Newcastle surveywas based on this definition. It has been criticized,but has lately received support from the careful,intensive and ingenious work of Fletcher and hiscolleagues at the Postgraduate Medical School.3

They conclude that there is an early phase ofhypersecretion of mucus which precedes the laterinfective stage. This fits well with the pathologicalstudies of Lynne Reid,19 who showed that mucoushypertrophy was an essential feature of the disease.Goodman, Lane and Rampling5 emphasized the

high mortality in the urban and industrial regionsof England and Wales, which they found to betwo or three times that of the rural districts.

TABLE I.-BRONCHITIS DEATHS 1954: RATES PER10,000 PER YEAR

Area Age 45-64 Age 65-74

M. F. M. F.Tyneside conurbation 10.9 1.9 38.8 I6.7S.E. Lancs. ,, 17.1 4.6 76.8 24.1S. Western region 5.9 1.0 30.2 6.5England and Wales 9.8 2.0 43.5 11.3

This work was published at about the same timeas that of Oswald," Lynne Reid, 18, 19 and May'0from the Brompton Hospital, so that both thechallenge and the knowledge essential to meet itappeared together.Goodman et al. underlined the association of

death from bronchitis in both sexes with 'urbani-

TABLE 2.-BRONCHITIS DEATH RATES PER 10,000(AGE 45-54), 1950

(Modified from Goodman, Lane & Rampling)

Bronchitis-- F/M.

Male Female Ratio

England and Wales .o.I.8 2.5 0.23All conurbation .. .. I3.7 3.1 0.23Urban areas with population

ioo,ooo or over .. .. 12.2 2.7 0.2250,000 and under ioo,000 io.6 2.6 0.25Under 50,000 .. .. 9.5 2.3 0.24Rural areas .. .. 5.5 1.3 0.24

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POSTGRADUATE MEDICAL JOURNAL

zation', and showed a progressive decline inmortality in relation to the size of towns.The term 'conurbation' is extremely ugly,

nearly as ugly as some of the 'conurbations'themselves, but seems to have come to stay. Itsmeaning may easily be guessed. The ratio offemale to male deaths is given in the form of aquotient, and it will be noticed that it is quiteunaffected by the size of the town. Both sexes areaffected equally by this, it would seem, and someother factor or factors must be involved in thisdifference between the sexes.The air over our large towns is known to con-

tain sulphur compounds, and these are known toaffect ciliary activity and mucous function inanimals, and there is some evidence that theycan do so in man, although there seems to bemuch variation in experimental work." 8

Stocks studied the relationship between hoursof sunshine and bronchitis deaths. He found thatthe less the hours of sunshine the higher the deathrate from bronchitis. Not only is sunshinebeneficial to health, but it causes polluting sub-stances to rise above breathing level. The positionin Newcastle may be assessed from the fact thatthe Medical School, which is not in the 'dirty'part of the city, receives goo hours of sunshine perannum, as compared with Bournemouth's 1,700.Pemberton and Goldberg'6 compared sulphur

dioxide pollution in 35 county boroughs, andshowed a direct relationship to mortality frombronchitis. Atmospheric pollution by chemicalpoisons is associated with soot and solid particles,and may be assumed to be present in very sooty'dirty' localities.A number of authors have shown a relationship

between cigarette smoking and bronchitis. Dolland Hill2 showed a rising mortality rate withrising consumption, and Higgins7a demonstratedan increase in respiratory symptoms, and adecrease in respiratory function in cigarettesmokers. Oswald and Medvei noted a similarassociation.'5When a survey of the city of Newcastle was

planned, the above environmental and socialfactors were uppermost in our minds, thoughconstitutional and infective influences were alsoconsidered as probably important. Stuart-Harris24stated that 'there is no doubt that . . . attacks ofacute bronchitis occur during the early life ofindividuals, who later become crippled fromchronic bronchitis'. In connection with thisview, overcrowding was an obvious target.The attempt to study these features was made,

although the difficulties inherent in a retrospectiveinquiry were appreciated.

In the social and environmental study of a long-continued disease such as chronic bronchitis, a

great difficulty is to estimate the predominantenvironment, and the social and other influencesover long periods of time. People move about,they change their jobs, and sometimes even theirhabits, and memories may play tricks.

This difficulty was met, as far as possible, byconcentrating on conditions of housing andoccupation, rather than upon actual houses andactual jobs, although these were also recorded.For example, if a person had lived in apparently'clean' areas of the city for most of his life, thiswas regarded as the important thing, no matterhow many houses he had lived in. Occupationalconditions we,re similarly classified.The city of Newcastle lies along the winding

river, which is narrow with steep banks. Most ofthe inhabitants still live within a mile of the riverbank. Rehousing has been actively pursued, but forlocal reasons a great many of the houses are just asclose to the river as their predecessors. The mainsource of pollution, the trains and industrial under-takings, are concentrated along the river (althoughthe diesel trains now running will no doubt reducethe total significantly) and the topography justdescribed is that generally considered to favourpollution. The domestic grate, also an importantcontaminator of the air, is more widespread, but,as will be shown later, it, too, is mainly con-centrated within a mile of the river.

This state of affairs gave rise to an expectationthat pollution may vary in different parts of thecity, particularly as the inhabitants are confidentin distinguishing between 'clean' and 'dirty'areas, these terms, of course, being in realityrelative only.

It was therefore possible to classify a locality as'clear' or as sooty and liable to damp and fog('not clear'), and a further classification of localityinto 'enclosed' and 'open' was made. The newerhousing is much better spaced than the old. Thedwellings stand farther apart, and there are spacesbetween them, in contradistinction to the oldertype of planning, where they are crowded closetogether with fewer openings. The air is muchmore likely to stagnate in this older arrangement,and pollution, when present, is thus more liable topersist.The photographs show the two types of locality

quite clearly and also that they can be readilydistinguished.

Fig. i shows the city divided by a line onemile from the river, into a riverside and a northernportion, the riverside being bisected into aneastern and a western area. The figures show thatdensity of housing and bronchitis go together andthat, though there is a relationship between thedisease and population, it is much less. In otherwords, it is overcrowding of houses, rather than

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April I960 OGILVIE: Social and Environmental Factors in Chronic Bronchitis 263

Showlnxirnz (7eclohsed tvpc of localitv.eI?x- kdiol( pfir fssi / '//w(l,'Guardian.

TABLE 3

Locality Bronchitis Controls Totals

Enclosed .. 249 (67%,h) 220 (54%) 469Open .1.I21 (33 °) 190 (46%) 311

Totals .. 370 (100%) 410 (I00%) 780

overcrowding of people, that is associated withbronchitis.The association of the 'enclosed' locality with

the disease, which is shown in Table 3, is notunexpected when one looks again at the map.But is this association perhaps more apparent

than real? Atmospheric pollution is likely, from

what has been said, to be more intense in theriverside areas and might perhaps of itself accountfor the result.That pollution is very likely to be more intense

at the river level and within 300 ft. of sea level isshown by Fig. 2, which is based on figures forGateshead, kindly given me by Dr. Grant.

Gateshead is directly opposite Newcastle, overthe river, and has a similar topography. It is at300 ft. above sea level that the city of Newcastle'flattens out' and extends towards its northernboundary, and the 'dirty' locality is less com-monly noted. Table 4 shows that the 'dirty'or ' not clear' districts have a significant associa-tion with the disease, but on further analysis it was

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264 POSTGRADUATE MEDICAL JOURNAL April I960

N-EWCASTLE upon TYNE

north

Bronchitis 23 (Population 22 per acreDwellings 7 6 per acre

Bronchitis 29Population 39 per acre

eSt Bronchitis 31 / Dwellings 10 3 per ocrePopulotion 51 1 per eastDwellings 111 ocre

FIG. I

*3

.E..

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April ig6o-' OGILVIE: Social and Environmiental Factors in Chronic Bronchitis z6

TABLE 4

Males Females TotalsLocality

Ch. Br. Controls Ch. Br. Controls Br. Controls

'Clear .. .. 78 94 67 102 145 (33%) 196 (46%)' Dirtv' 194 135 125 95 329 (67%) 230 (54%)

272 229 192 197 474 426

TABLE 5.-EARLY ACUTE RESPIRATORY EPISODES

Males Females

Bronchitics Controls Bronchitics Controls

No. % No. % No. % No. %

Recurrent early episodes .. .. .. 43 I6 I5 6 51 27 I9 8Infrequent earlv episodes .. .. 229 84 224 94 141 73 227 92

Totals .. .. 272 239 192 246

ascertained that within this locality the enclosedtype of housing was still definitely associatedwith bronchitis. It should be mentioned here thatsmoking habits were found not to vary withlocality and that they do not' affect these con-clusions.

This finding seems to confirm the suggestionmade earlier that the effect of 'enclosed' housingis to aggravate the effects of atmospheric pollutionwhen it exists.The importance of cigarette smoking is dealt

with in the discussion later.With regard to the significance of acute bron-

chitis in early life, the objection can be raised thatthe individual who suffers from respiratory diseaseis more likely to recall early bronchial illnessesthan the healthy person. Therefore, the figuresgiven in Table 5, significant though they are,must be regarded with that possible criticism inmind.But it is seen that such early illnesses were

found to be twice as frequent amongst chronicbronchitics as amongst healthy controls and theevidence is regarded as strongly suggestive.

Further evidence of infection was obtained byascertaining the frequency of acute bronchitis atthe time of the inquiry. This also showed doublethe number of bronchitics reporting annual bron-chitis as were found amongst the non-bronchiticcontrol group. The evidence of infection is thusstrong and we know from the pathologists that itis an essential feature of the disease.

Family bronchitis was a significant finding, butits influence in regard to total prevalence is difficultto assess. No evidence of the existence of the'bronchitic household' was elicited.

AIMlOSP1.ERIC PCuLuriorGCP6rESAHEfD-ON -r7YXIqS6

601-AL SOLaDS

tp8 (PREPARED FROM FI&k.v( KIP|NDLY SUPP,1lEJD as3R J GRArJr a")

40

30

'5 ' /

,4\/

ao

j

0-A

FIG. 2

Evidences of allergic illnesses in the family werenot significant, but personal allergic manifestations(asthma, rhinitis, eczema and nettle rash) weremore than twice as frequent among bronchitics.There is in all this some evidence which suggeststhat contributional factors play some part in thedevelopment of the disease, although it has notproved possible' to say how important this partmay be.

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266 POSTGRADUATE MEDICAL JOURNAL April I96o

Brnchitis (England &Wales)spels d certifed incapacity - 1956;Men. By Regions (related to population of risk.)

I-,C

r0 WS,

zo& 4- 8

.,, yX S ............................'4 s| a

3

FIG. 3

TABLE 6

Male MaleBronchitics Controls

UnemploymentNo. % No. %

None or under 2 years i 8I 67 200 842- 5 years .. .. 47 17 I9 86-Io ,, .. .. 32 12 12 5I iyears and over .. I 44 8 3

Totals .. .. .. 272 100 239 100

The only evidence regarding a nutritional in-fluence on prevalence which we have was providedby the survey and is given in Table 6. Thisshows that prevalence varies with the total dura-tion of unemployment between the wars. Itmight be thought that this could be related moreto social class rather than to unemployment assuch, because social classes III and V sufferedmore than others from unemployment. This,however, is not so and the association is a true one.There is thus an indication that there is an

economic factor which cannot be ignored.

DiscussionThe evidence that even within an industrial

city with 9.4 houses per acre an association ofbr'onchitis with atmospheric pollution and withdensity of housing exists, does seem to offer apossible explanation of the influence of 'urbaniza-

tion' noted by Goodman, Lane and Rampling,in relation to mortality.

Constitutional, and possibly hereditary in-fluences, are significant in a proportion' of cases,and an economic association' is seen in the relationto unemployment.On the evidence regarding mortality, the

natural 'expectation was that' general prevalencewould follow a similar pattern, being higher'intown than in country. Several rural surveys havenow been conducted however, which suggestthat there is, in fact, very little difference betweentown and country, in so far as general prevalenceis concerned.

In two of these, comparisons with urban surveysby the same authors were possible, and theprevalences were similar. Neither Higgins, norStuart-Harris and Hanley referred to their casesas 'chronic bronchitis', but they investigated thefrequency of persistent productive cough. This is'chronic bronchitis' according to the Newcastledefinition, which has been given implied recogni-tion by the recommendations of the Ciba GuestSymposium,20 which define chronic bronchitisas 'the condition of subjects with chronic orrecurrent excessive mucous secretion in thebronchial tree'.There is thus no evidence that bronchitis is

necessarily more frequent in the town than it isin the country. How can we correlate theseobservations? The most obvious explaniation is avariation in severity. If more people die ofbronchitis in the town, and yet the disease is

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April 96o OGILVIE: Social and Environmental Factors in Chronic Bronchitis 267

spells. of incopocity from All Causes -l956P-teporedirom M.PN.I. Digest of Sto-tistics

0.

FIG. 4

roughly as prevalent in the country, it is probablymore severe in the town-dweller. If this is so, therate of invalidism in urban districts must begreater, and this is found to be the case.

Fig. 3 illustrates this point. As one passes fromleft to right, one passes from the highly industrialand urban communities to the rural and resi-dential towns and villages, and the rate of certifiedsickness from bronchitis falls.

This graph is even more striking when comparedwith the certified sickness from all cau'ses,analysed by regions in the same way (Fig. 4). Theclassification by 'spells' is not a very satisfactoryone, as the 'spells' naturally vary in duration, butthis consideration cannot disturb the general,conclusion: namely, that urban conditions arerelated closely to incapacity due to bronchitis,b:ut not to total incapacity in the insuredpopulation.

Further evidence which suggests that urbanconditions act by aggravating bronchitis is to befound in the study by Logan and Cushion9 ofmorbidity in general practice. They used,various methods to ascertain the calls made onthe services of a sample of general practitioners,and the causes.The most reliable method seemed to be the

'patients' consulting rate. This classified by causethe numbers of patients per I,ooo population whoconsulted their doctor during the twelve monthsMay, 1955, to April, I956.This showed that there was still a definite

trend for the predominantly rural regions to have

Bronchitis in General Priaicepotients aonsultinq rates per 1000 population

(by REG ION) Loqon i Cushion

2043;1-0 S l-FIG. 5

a lower rate of consultation for bronchitis, althoughthe tougher Northerner complains less.The rates for the sexes. still show, male prepon-

derance, but to a less extent than prevalence rateswould lead us to expect.

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Our conclusion can only be that bronchitis ismore severe, more disabling, and more fatal inthe town-dweller than it is in the countryman.Why is this? One reason, in all probability, is

atmospheric pollution, the effect of which isincreased by 'enclosed' housing, a type of townplanning so widespread in the older areas of ourcities.Smoking habits must be given a high place.

Reid"7 deals with this, and considers that a verystrong suspicion that the cigarette is an importantaggravating factor is fully justified.

Todd25 found that the country dweller smokeson average two cigarettes daily fewer than thetownsman. This is not a gross difference (9 againstii), but it means 730 cigarettes a year, and in 20years 14,600 cigarettes, and cannot be ignored as apartial explanation of the higher prevalence ofaggravated bronchitis in the towns.The high male prevalence and mortality are

almost exactly double the female rates. In New-castle the figure was 36% for men, and I7% forwomen, aged 30 and over.The possibility that this difference is largely

due to smoking habits is suggested by the factthat in Newcastle 83% of male bronchitics, andonly 41% of female bronchitics were smokers, andthat the male addiction was heavier.

If the smokers are considered separately,without consideration of the degree of addiction,59% of the men, and 56% of the women, arefound to have chronic bronchitis.Oswald and Medvei,15 in an investigation of

respiratory symptoms in Civil Servants, whereworking and living conditions were similar, foundthat the prevalence of bronchitis amongst non-smokers and smokers, considered separately,showed no difference in incidence between malesand females.

Fletcher et al.3 noted a sex difference betweenmale and female smokers, but this diminished withincreasing consumption. A similar result wasobserved in the Newcastle series, when thegreatest amount ever smoked regularly is com-pared; but if all smokers are added together thedifference is small, as the percentages alreadygiven show.

It seems possible, and even likely, that smokinghabits account for a considerable part of thedifference in sex incidence.The Newcastle non-smokers and pipe smokers

have not been compared. Male non-smokers werevery few, and pipe smokers were shown byFletcher et al.3 to be not strictly comparable withnon-smokers.

Olsen and Gilson13 studied the prevalence ofrespiratory symptoms and ventilatory capacity in

men in Bornholm, which they compared withrural studies in Wales and Scotland. Theyfound a significantly lower prevalence in Born-holm, but noted that in the group of non-smokersthere were no differences, clinical or physiological.It appeared that the whole of the difference couldbe explained by the cigarette consumption in thepopulations concerned. This shows that preva-lence can vary with smoking habits.

Further progress depends now on the study ofaggravated bronchitis: and this waits for anacceptable clinical definition. This is a mostdifficult problem, which has not been solved asyet.

Chronic bronchitis, like the gentle districtvisitor, 'eschews melodrama', although, also likethe gentle district visitor, melodrama breaks innow and then (Gilbert, I887).4

SummaryThis discussion of the important social and

environmental factors in chronic bronchitis hasbeen based on a review of the findings of a surveycarried out in Newcastle in 1955-56 (Ogilvie andNewell, 1957),12 and amplified by reference to therelevant literature.

It has been noted that mortality and sicknessdue to bronchitis both bear a direct relationshipto the degree of urbanization, and are lowest in thecountryside.

Pollution of the atmosphere has been con-sidered to be a major aetiological and aggravatingfactor, but it has been emphasized that its effectsare much enhanced by the older 'enclosed' typeof housing arrangement.

It has been observed that urban life, though itaffects the rates for death and for incapacity, doesnot alter the male preponderance, which is seenalso in general prevalence. It is found, however,that the difference is greatly reduced, if smokersand non-smokers are separately analysed. It isconsidered that cigarette smoking, which has beenshown to affect general prevalence, and is thoughtto cause aggravation, is the chief cause of theexcess of bronchitis in the male.

Constitutional influences are significant,although no accurate estimation of their import-ance is yet possible. Infection, though known tobe an essential feature of established bronchitis,is difficult to demonstrate epidemiologically.The fact that rural prevalence almost equals

urban prevalence, despite the higher death andsickness rates, indicates that the town-dweller'sbronchitis is more severe, and underlines theneed for clinical criteria of aggravation, so thatstudy of the causes of aggravatlon can go forward.

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April I960 OGILVIE: Social and Environmental Factors in Chronic Bronchitis 269

AcknowledgmentI must thank Messrs. E. & S. Livingstone Ltd.,

of Edinburgh, for permission to publish certaintables and figures from ' Chronic Bronchitis inNewcastle upon Tyne.'

REFERENCESx. CRALLEY, L. V. (1942), 7. industr. Hyg., 24, 193.2. DOLL, R., and HILL, A. B. (r9s6), Brit. med. Y., ii, 1071.3. FLETCHER, C. M., ELMES, P. C., FAIRBAIRN, A. S., and

WOOD, C. H. (1959), Ibid., ii, 257.4. GILBERT, W. S. (i887), 'Ruddigore,' Act 2.<. GOODMAN, N., LANE, R. E., and RAMPLING, S. B.

(I9S3), Brit. med. J., ii, 237.6. HIGGINS, I. T. T., OLDHAM, P. D., COCHRANE, A. C.,

and GILSON, J. C. (1956), Ibid., ii, 904.7. HIGGINS, I. T. T. (1957), Ibid., ii, I198.7a. HIGGINS, I. T. T. (I9S5), Ibid., i, 323.8. LAWTHER, P. J. (I95S), Lancet, ii, 745.9. LOGAN, W. P. D., and CUSHION, A. A. (1958), 'Studies on

Population Subjects, No. I4,' H.M.S.O., London.io. MAY-see Report-marked in reference.

iI. MINISTRY OF NATIONAL INSURANCE (xt96), 'Digestof Statistics analysing Certificates of Incapacity.'

I2. OGILVIE, A. G., and NEWELL, D. J. (1957), 'ChronicBronchitis in Newcastle upon Tyne', Edinburgh: E. & S.Livingstone Ltd.

13. OLSEN, H. C., and GILSON, J. C. (I960), Brit. med. J., i, 450.14. OSWALD-see Report-marked in reference.I5. OSWALD, N., and MEDVEI, V. (i95S), Lancet, il, 843.i6. PEMBERTON, JOHN, and GOLDBERG, C. (I954), Brit.

med. J7., iI, 567.17. REID, D. D. (I958), Lancet, i, 1289.I8. REID, LYNNE, McA. (I954), Ibid., is .275.I9. REID, LYNNE McA. (I955), Thorax, Io, i99.2o. Report of the Conclusion of a Ciba Guest Symposium (i959),

Ibid., 14, 286.21. STOCKS, P. (1947), 'General Register Office, Studies on

Medical and Population Subjects, No. i,' H.M.S.O., London.22. STUART-HARRIS, C. H., and HANLEY, T. (I958), 'Chronic

Bronchitis, Cor Pulmonae, and Emphysema.'23. STUART-HARRIS, C. H., POWNALL, M., SCOTHORNE,

C. M., and FRANKS, Z. (1953), Quart. J. Med., 22, 121.24. STUART-HARRIS, C. H. (I954), Brit. J. Tuberc., 48, 169.25. TODD, G. F.. (xrg5), 'Tobacco Manufacturers' Standing

Committee, Research Papers, No. i, Statistics of Smoking,'2nd Edition, London.

References continued from page 275-Enquiries into Mental Disorder in Old Age.xi. HILLBOM, E. (I960), Acta. Psychiat. et Neurol. Scand. Suppl.

I42.

I2. HILLIARD, L. T., and KIRMAN, B. H. (I957), 'MentalDeficiency,' London, J. and A. Churchill.

13. HOPKINS, B., and ROTH, M. (r953), J. Ment. Sci., 99, 451.14. HUTCHINSON, E. C., and YATES, P. O. (I957), Lancet, 1, 2.Is. KAY, D. W. K. (I9s5), Proc. Roy. Soc. Med. 52, No. 9, 791.I6. KAY, D. W. K., and ROTH, M. (I955), Lancet, ??, 259, 740.17. KAY, D. W. K., and ROTH, M. (I960), to be published.i8. MALLER, 0. (I959), 'Les Particularites Nosologiques de la

Schizophrenia. In: Congress Report, II,63. 2nd InternationalCongress for Psychiatry, Zurich, 1957.

19. MALZBERG, B., and LEE, E. S. (I956), 'Migration andMental Disease,' New York, Social Science Research Council.

2o. MAYER-GROSS, W., SLATER, E., and ROTH, M. (1954),'Clinical Psychiatry,' London, Cassells.

2t. MAYER-GROSS, W., SLATER, E., and ROTH, M. (I960),Ibid.

72. ODEGAARD, 0. (1932), Acta. psychiat. et neurol., Suppl. 4.23. ODEGAARD, 0. (953), Acta. psychiat. scand., Suppl. 8o.24. ODEGAARD, 0. (1959), 'The Epidemiology of Schizophrenia

in Norway,' Report of 2nd International Congress for Psy-chiatry, Vol. III, 49-52, Zurich, 1957.

25. POLLACK, B. (X939), N.Y. St. J. Med., 39, 43I.26. REGISTRAR-GENERAL (1954), 'Statistical Review of Eng-

land and Walep for the year 1953. Part I: Tables, Medical,'H.M.S.O., London.

27. REGISTRAR-GENERAL (1956), 'Statistical Review of Eng-land and Wales for the year I955. Part I: Tables, Medical,'H.M.S.O., London.

28. ROSE, N. M., and STUB, H.\R. (1956), 'Mental Health andMental Disorder,' London.

29. ROTH, M. (x955), 7. ment. Sci., Ioi, 28i.30. ROTH, M., and HOPKINS, B. (1953), Ibid., 99, 439.31. ROTH, M., and KAY, D. W. K. (I956), Ibid., I02, r4l.32. ROTH, M., and MORRISSEY, J. D. (1952), Ibid., 99, 439.33. ROTH, M., OSSELTON, J. W., and GREEN, T. (I960), to

be published.34. SAINSBURY, P. (I9ss), 'Suicide in London,' Maudsley

Monograph No. x, London, Inst. of Psychiat.35. SJOGREN, T., and LARSSON, T. (I954), Acta. psychiat. et

neurol., Scand. Suppl. 89.36. SLATER, E. (I959), Paper delivered at Maudsley Symposium

on Epilepsy, to be published.37. STENSTEDT, A. (i959), Acta. psychiat. Khb., Suppl. 127.38. TOWNSEND, P. (1957), 'The Family Life of Old People,'

Routledge, London.39. WALTHER, B. H. (I95I), 'Psychiatry of Cerebral Tumours

and the Problem of Focal Syndromes and of PsychologicalLocalisation,' Vienna.

40. WORLD HEALTH ORGANIZATION (i959), 'MentalHealth Problems of Aging and the Aged.' Sixth Report ofthe Expert Committee on Mental Health, Technical ReportSeries, No. 171.

41. WEINBERG, W. (1925), in 'Handbook of social hygiene andpublic health', Vol. i, Berlin.

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