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How far are accidents to young children at home avoidable?
PUBLIC HEALTH, June, I953
I3z HOW FAR ARE ACCIDENTS TO YOUNG CHILDREN AT HOME AVOIDABLE ? *
By E. CATHERINE MORRIS JONES, M.B., D.P.H.,
Senior Medical Officer, Maternity & Child Welfare, Gloucestershir e I n obtaining details for the A n n u a l Report of 1950 I was struck by the unduly high n u m b e r of children u n d e r one year w h o s e death was attributed to some kind of acci, dent ; and I felt that this topic, e x p a n d e d up to five years, might f o r m the basis of m y presidential talk. Since that time there has been a plethora of pamphlets, articles, and statements on this general subject of h o m e accidents, and it seemed that all the points I m i g h t have brought forward for your consideration had already been discussed by m u c h abler people. However, I decided to continue in m y purpose. T h e r e is an advantage in putting together the observations of the experts, which I have shamelessly done ; and if any excuse is needed for m y choice it is that the subject is " topical " ; and I can only hope t h a t if you have read the various articles you have long forgotten them. T h e extent of m y t h e m e is, firstly, to set out the scope of the p r o b l e m relating to young children ; secondly, to give a brief outline of the more c o m m o n accidents ; thirdly, to discuss whether they are in whole or in part avoidable ; and lastly, to envisage the place of the public health service in this matter. Scope I n the Monthly Bulletin of the M i n i s t r y of H e a l t h for January, 1952, Dr. Boucher 1 informs us that in E n g l a n d and Wales each year about 6,000 persons die as a result of domestic accidents, i.e., 46% of all fatal accidents. As h o m e accidents are not notifiable, t h e n u m b e r of non-fatal accidents cannot be accurately determined ; b u t an e s t i m a t e of a 4 % annual h o m e accident rate of the population' has been m a d e where such accidents are of sufficient severity to require hospital treatment. The n u m b e r of m i n o r aceidents is completely .unknown at the present time. O f the fatal accidents 20%, or approximately 1,200, occur in children u n d e r five, and in children between one and five a fatal h o m e accident is the third largest cause of death. Information on non-fatal accidents will sometimes be ascertained from hospital records, child welfare centre case sheets or in conversation with mothers, and in our own families, and it is apparent that the child in his first five years is particularly liable to hazards in the home. Apart from the distress caused to the family by death following an accident, there is the possibility of long stay in hospital with permanent disability or disfigurement, which may affect the outlook of the child. It m a y be that m i n o r accidents w i t h complete recovery are part of the child's normal adjustment to his e n v i r o n m e n t and as such are beneficial to his true education,. T h e p r o b l e m related to young children is therefore of a degree to merit special consideration. Causes W h a t are the risks inherent in the h o m e e n v i r o n m e n t ? T h e y are legion and impossible to enumerate in d e t a i l : burns due to ignition of clothing or playing with matches ; strangulation with a p r a m harness or between the bars of a cot ; scalding from the upsetting of some utensil concerned in that British Institution " t h e cup of t e a " ; swallowing of poisonous substances ; falls down u n g u a r d e d stairs, or cuts from untimely play with scissors or knives. Some injuries are of a very transitory nature but all such make up a large sum total of accidents. I do not propose to deal in detail with each type of misfortune but to select certain groups for m o r e exhaustive consideration.
Presidential Address to the West of England Branch, Society of M.O.H., Taunton, October 4th, 1952.
(1) Burns and Scalds T h e largest group of serious accidents to young children about which detailed information is available is that involving burns and scalds. W h e r e hospital treatment was necessitated the reports published in 1949 and 1951 by L. & V. Colebrook 2 g~ve a comprehensive picture ; 1,374 out of 2,000 consecutive cases of burns and scalds admitted to the B i r m i n g h a m A c c i d e n t Hospital were due to causes in the h o m e ; 737, or 53%~ occurred in children under five ; 435 o f the 650 scald cases (67%) and 302 of the 724 b u r n cases (41%); It w o u l d appear t h a t injury from scalding is therefore one o f the commonest risks for a child. Of these cases 63% were occasioned by the upsetting of containers of hot fluids : kettles, saucepans, teapots, tea-cups, etc. ; 17~o by falling into baths or buckets of hot water, and 20% in other ways. A m o n g these cases there w e r e three deaths. W e cannot compute the amount of family distress caused through such accidents but we know t h a t an average of 31 days' stay in hospital was involved. I n relation to the 302 cases of burns, 176 occurred as a result of direct or indirect contact with a domestic fire, electric, gas or coal, and that 149 of these fires w e r e u n g u a r d e d at the time of the accident. T h e remaining 126 cases were due to miscellaneous causes : burns from inflammable gases, bonfires, fireworks, hot fat, falling on hot metal or ashes, matches, etc. In 93 of all the cases clothing caught fire and the 12 deaths in the group were all associated with this fact. W i t h m o d e r n treatment burn patients do not often die to-day unless their injuries are extensive, and this is likely to be the case w h e n clothing catches fire. T h e risk to children f r o m heat, which is an essential utility in the home, is therefore not inconsiderable.
(2) Suffocation W e are all familiar with the death certificate of suffocation, sometimes due to swallowing of a foreign body as a balloon, to j a m m i n g of head between cot bars, to plastic bibs, to smothering by a cat, to overlaying in bed or to regurgitation and inhalation of food ; also sometimes alleged to be due to smothering by a soft cot pillow or bedclothes or to lying on the face in the cot, a n d are apt to consider these occurrences should n e v e r have happened. T h e average annual n u m b e r of deaths ascribed to accidental mechanical suffocation is about 600 a year. Such deaths have a peculiar poignancy, as they occur p r e d o m i n a n t l y in children u n d e r one year of age, and frequently to first children. M u c h distress is caused to a family in which such an event happens, often w i t h a lasting feeling of guilt of the mother or nurse responsible for the infant. In this connection I should like to draw your attention to articles by Keith Bowden 3 a n d Douglas Swinscow ~. T h e s e writers express the view that because a child is found dead in a cot face downwards or beneath the bedclothes the death should not ipso facto be attributed to accidental suffocation, but may be due to some undiscovered or unree0gnised disease. Cases are-quoted of children thought to be quite well even by trained observers dying suddenly during or following a feed, with or without vomiting occurring, and of instances in which, on careful consideration after the death, the parent remembers that the child had been unnaturally quiet or peevish for a period beforehand. Meticulous post-mortem examination-4n such cases revealed the p r e s e n c e of organic disease, acute interstitial myocarditis, acute nephritis, disease of ear and mastoid a n t r u m , b r o n c h o - p n e u m o n i a and other lung infections, which had been completely unsuspected. T h i s leads t h e m to believe that rapid changes may take place in body tissue in disease w h i c h m a y lead to sudden deaths in infants with little or no evidence of illness. T h e y do not deny that mechanical suffocation does take place ; .but consider that suffocation from inhalation of vomitus in cot, or due to covering with bedclothes, is a rarity in a healthy infant. M o s t infants w h e n they can m o v e freely t e n d to t u r n on to their faces in their cot, and even go u n d e r the clothes ; but a healthy baby can extricate himself f r o m this
PUBLIC H E A L T H , June, .t953 position w h e n h e wishes to do so, or cry o u t if h e c a n n o t free himself. S h o u l d a child w h o is suffering f r o m some disease w h i c h is r u n n i n g a swift course get into this position, he m a y well be expected to m a k e little s o u n d or effort i n his del3arture , a n d i n d e e d i n n o t all cases is the n o s e a n d m o u t h o c c l u d e d b y the b e d d i n g . T h e p r e s e n c e of v o m i t u s in the air pass ages alone is n o t evidence t h a t this was t h e sole cause of d e a t h for v o m i t i n g is a c o m m o n t e r m i n a l event in disease. I n 1945 post-mortems were carried out i n B i r m i n g h a m o n every case in w h i c h asphyxia was c o n s i d e r e d t h e possible cause of death, a n d o u t of 318 cases in only 24 was t h e asphyxia caused mechanically. S w i n s c o w has s h o w n t h a t the n u m b e r of certificates of deaths of suffocation of i n f a n t s " in b e d , " i.e., w i t h o t h e r people, has declined recently whereas those f r o m suffocation " in cot " or " b y food " have risen. T h e b u r d e n of b o t h writers is t h a t n o i n f a n t s ' d e a t h s h o u l d b e a t t r i b u t e d to suffocation unless t h e r e is cleat post-mortem evidence to s u p p o r t this view. (3) Poisoning T h e periodic o c c u r r e n c e of p o i s o n i n g of y o u n g c h i l d r e n is c o m m o n knowledge, s o m e t i m e s arising f r o m tablets issued to t h e m o t h e r b y a local a u t h o r i t y clinic. T h e giving of aspirin c o m p o u n d s , fersolate, etc., to a y o u n g e r child b y one only a little older as sweets, h a p p e n s almost daily, t h o u g h f o r t u n a t e l y is n o t i n v a r i a b l y fatal. T h e d r i n k i n g o f lethal liquids f r o m bottles left o n tables or t h o u g h t to b e j u s t out of r e a c h is a f r e q u e n t h a p p e n i n g in t h e h o m e . (4) Other Causes Falls. T h e s e do n o t so f r e q u e n t l y occur to y o u n g c h i l d r e n w h o are left to t h e i r explorations w i t h o u t u n d u e i n t e r ferences ; like a cat a child can achieve great feats of balance, b u t if startled a n d t h e i r sense of c o n c e n t r a t i o n a n d equilib r i u m are d i s t u r b e d a t u m b l e w i t h resulting bruises m a y follow. Cuts f r o m knives, scissors or b r o k e n glass a n d c h i n a m a y p r o d u c e f r i g h t o u t of all p r o p o r t i o n to t h e degree of t h e injury, b u t rarely p r o d u c e death. Electrocution f r o m faulty installations is b u t a snlall cause of i n j u r y to y o u n g children. T h e s e are b u t a few of c o n l r n o n daily occurrences.
Avoidance of Accidents T h e r e is a fallacy in the title of this paper. A c c o r d i n g to definition a n accident is an e v e n t w i t h o u t a p p a r e n t c a u s e - - a n u n f o r e s e e n e v e n t - - t h e r e f o r e strictly such events are u n a v o i d a b l e ; or m o r e p o p u l a r l y u n p r e v e n t a b l e . A n d t h e r e I could stop. B u t it is also defined as an u n i n t e n tional act, w h i c h is a definition m o r e applicable to t h e m a t t e r s we are c o n s i d e r i n g - - t h e act occasioned b y default r a t h e r t h a n b y design. S o m e c o m p l a c e n t l y declare t h a t " A c c i d e n t s will h a p p e n " : o n t h e o t h e r h a n d , it is c o m m o n parlance to say t h a t the e v e n t is m o s t often due to c a r e lessness, a n d w h e r e y o u n g c h i l d r e n are involved to t h e carelessness of t h e m o t h e r . A r e we fair in p u t t i n g the b l a m e for all injuries great a n d small o n t h e housewife ? T h e r e can b e ~few m o t h e r s w h o deliberately expose t h e i r c h i l d r e n to 'danger. S o m e are n o t sufficiently i n t e r e s t e d to take all m e a s u r e s to p r o t e c t t h e m a n d s o m e - - t h e larger n u m b e r - - w o u l d take all possible care b u t are i g n o r a n t of the d a n g e r spots in t h e i r h o m e s or are u n a b l e to p r o v i d e the essential safeguards. O t h e r s again will m a k e efforts to follow s u c h practices as t h e y m a y b e advised, a n d if this advice is i n a d e q u a t e or i n c o m p l e t e t h e y are given a sense of false security. W h e r e can action be t a k e n t h a t will reduce the c h a n c e of accidents ? It h a s b e e n d e m o n s t r a t e d b y m a n y people t h a t t h e risk of accidents is greater in o v e r c r o w d e d homes, b a d l y c o n s t r u c t e d houses, a n d a m o n g t h e lower i n c o m e groups. I n a series-of 50 cases of b u r n s in G l a s g o w 45 of the c h i l d r e n came from homes where there was: overcrowding and squalor, w h e r e the s t a n d a r d of h o m e - c r a f t was poor, a n d the m e n t a l capacity, a n d s o m e t i m e s t h e physical capacity, of t h e m o t h e r low. T h o s e w h o have d o n e m u c h work in this field tell us t h a t
z33 t h e m a i n w e a p o n in t h e a r m a m e n t a r i u m m u s t be e d u c a t i o n - - t a l k s , posters, d e m o n s t r a t i o n s to g r o u p s of all ages, c o m m e n c i n g w i t h c h i l d r e n at school. Will t h i s achieve t h e p u r p o s e ? Firstly, we m u s t b e careful w h a t we t e a c h as it is n o t e n o u g h to advise generally w i t h o u t specific directions. I n this c o n n e c t i o n consider t h e m a x i m advising m o t h e r s to h a v e a fireguard, i n C o l e b r o o k ' s series 26 of t h e b u r n injuries were i n cases w h e r e a fireguard Was present, b u t w h a t k i n d of a g u a r d ? T h e essentials of a t r u e g u a r d m u s t b e p o i n t e d at. T h e y m a y b e w a r n e d of the dangers f r o m containers of h o t l i q u i d s ; b u t t h e usual type of p a n o b t a i n a b l e at a reasonable cost h a s a p r o j e c t i n g handle, a n d m o s t kettles a n d all tea cups are top h e a v y a n d easily u p s e t ; n o t so b e e r mugs, a l t h o u g h t h e y are n o t d e s i g n e d for t h e use of c h i l d r e n ! M o d e r n design can p r o d u c e p a n s a n d kettles w h i c h are n o t top heavy, b u t t h e y are expensive, a n d s u c h d r a w b a c k s m u s t be b o r n e i n m i n d i n t h e advice given. E d u c a t i o n i n the h o m e is of greater value, t h e p o i n t i n g o u t to a m o t h e r in h e r o w n h o m e of s o m e f a u l t of e q u i p m e n t or practice will have a m o r e lasting effect t h a n a general discourse o n t h e dangers t h a t lurk i n houses, details of w h i c h m a y n o t b e t a k e n to h e a r t b y t h e i n d i v i d u a l . " I t n e v e r will h a p p e n to m e l " P e r h a p s t h e b e s t e d u c a t o r is t h e o c c u r r e n c e of a serious accident, n o t only to t h e family c o n c e r n e d b u t to those a r o u n d . F o l l o w i n g a r e c e n t case of d e a t h in o u r c o u n t y d u e to a child swallowing almost a w h o l e b o t t l e of aspirin, m o r e t h a n one m o t h e r , r e a d i n g of t h e h a p p e n i n g in t h e e v e n i n g paper, w e n t i m m e d i a t e l y to b e assured t h a t all s u c h n o x i o u s s u b s t a n c e s were well away f r o m t h e r e a c h of h e r o w n child. I t is rarely t h a t a serious a c c i d e n t occurs twice i n t h e same family f r o m t h e same cause. I a m n o t d e c r y i n g s p r e a d i n g the gospel of p r e v e n t i o n b y education, or t h e efforts of those e n g a g e d i n this work, b u t it is a slow process, often d i s r e g a r d e d b y those w h o n e e d it m o s t , a n d in m a n y cases has p o o r material to work on, a n d m e a n w h i l e the n u m b e r o f h o m e accidents has n o t decreased v e r y m u c h since 1943. Is t h e r e n o o t h e r way b y w h i c h some of t h e risks could b e r e d u c e d if n o t e n t i r e l y e l i m i n a t e d ? W h a t of t h e L a w ? T h e r e is legislation c o n c e r n i n g t h e p r o y i s i o n of fireguards in certain c i r c u m s t a n c e s w h e r e c h i l d r e n are involved, h u t we k n o w it is a law h o n o u r e d m o r e in t h e b r e a c h t h a n in t h e o b s e r v a n c e and, b e i n g so e x t e n sively disregarded, is of little value. W o u l d f u r t h e r legislation applied to p e r s o n s i n t h e i r h o m e s b e of m u c h avail w i t h o u t s u c h " s n o o p i n g " as w o u l d restrict t h e f r e e d o m of t h e h o m e ? Is n o t t h e n e e d n o w for action to be t a k e n outside t h e h o m e ? T h a t some regulations m i g h t well be m a d e has b e e n t h e view of v a r i o u s b o d i e s for some t i m e - - F e d e r a t i o n of W o m e n ' s Institutes, N a t i o n a l Council of W o m e n , a n d so on. C o l e b r o o k h a s d r a w n u p a n a t i o n a l plan for t h e r e d u c t i o n of b u r n i n g accidents a n d t h e I n t e r - d e p a r t m e n t a l C o m m i t t e e set u p b y t h e H o m e Secretary in 1947 has b e e n w o r k i n g to t h e same end. T h e s e efforts r e s u l t e d in t h e B u l l a r d F i r e g u a r d Bill, w h i c h received its t h i r d r e a d i n g in J u n e , 1952. T h e B~itish S t a n d a r d s I n s t i t u t i o n 5, 6 has c o n s i d e r e d s t a n d a r d safety specifications for electric fires, a n d a m i n i m u m s t a n d a r d of safety, a satisfactory s t a n d a r d of m e c h a n i c a l a n d electrical construcfion~ h a s b e e n set out. E v e n w i t h s u c h i m p r o v e m e n t s as these m a y have it is specifically stated t h a t " t h e p r e s e n t s t a n d a r d is restricted t o p r o v i d i n g p r o t e c t i o n to p e r s o n s f r o m accidents s u c h as m a y arise t h r o u g h negligence a n d t h o u g h t l e s s n e s s o n t h e p a r t of able a d u l t s - t h e y are n o t suitable w i t h o u t f u r t h e r p r o t e c t i o n for use in r o o m s occupied b y u n a t t e n d e d y o u n g c h i l d r e n " : so o u r p r o b l e m is n o t yet m e t in full. Similar s t a n d a r d s have b e e n laid d o w n for gas fires, w i t h t h e same provisos. B r i t i s h S t a n d a r d s set u p only a code of practice w h i c h is n o t c o m p u l s o r y o n m a n u f a c t u r e r s unless m a d e so b y law, a n d a f u r t h e r p o i n t arises. Articles c o n s t r u c t e d i n accordance w i t h t h e s e specifications are expensive, a large p a r t of t h e cost b e i n g p u r c h a s e tax, w h i c h is a p p r o p r i a t e d b y t h e G o v e r n m e n t . A s t a n d a r d type of fire m a y cost s (s P.T.). Is it u n r e a s o n a b l e to ask t h a t p u r c h a s e tax s h o u l d b e r e m o v e d f r o m articles for use in h o m e s w h e r e
I34 there are y o u n g children, and where their safety is of p a r a m o u n t importance. A n analogy with such a suggestion is to be found in industry where protective clothing is free of purchase tax. Also in relation to guarding of coal fires there are m a n y types of guard on the market ranging in price f r o m 9s. to 35s., but the Safety value does not always bear a relation to the cost. Some of the fastenings are so inadequate they can be easily u n d o n e by an active toddler and some have none at all. A great m a n y require removal for refuelling of the fire and u n d e r pressure of her duties the mother m a y not i m m e d i a t e l y replace the guard. People are accustomed these days to expect that the goods offered for sale are guaranteed for their purpose. T h e y do not question the safety of a p o u n d of sausages or a pint bottle of milk, but legislation has been r e q u i r e d to reach this stage. M u c h danger m a y be caused by the use of faulty e q u i p m e n t bought on account of its cheaper cost and with purchaser unaware of the absence of real safety. Manufacturers and retailers .supply the current demand, and unless a demand is made for a safe article the cheaper faulty risk-carrying one will gain the day. T h e Housing Manual, 19497 draws attention to the need for ensuring that proper fixtures for securing fireguards are provided in n e w houses but this is not always carried out. T h e provision of suitable fixtures involves little additional cost at the time of construction of the house but the lack of it m a y result in serious damage to the children. A n d w h y stop at fixtures ? Cannot Local Authorities make provision w h e r e b y adequate fireguards can be loaned for hire at a charge ? T h i s is done in E d i n b u r g h and is a useful lead for other authorities. It m i g h t even be possible where there are children u n d e r five years to arrange for an approved guard to be purchased f r o m a retailer at cost price or less, the balance of the full purchase price being paid by the Local Authority. T h e Bill to which I have previously referred is the H e a t ing Appliances (Fireguards) Bill s brought forward by a private m e m b e r , Mr. Bullard. T h e purpose is to prevent the sale in shops of electric and gas fires and oil stoves unless they are fitted with an adequate fireguard. T h e Bill is n o w on t h e Statute Book and the making of the date on which the regulations come into force and the fixing of standards will be laid down in due course and m a y welt prove one of the most important advances in which avoidance of bumir/g accidents will be brought abouL A n y official supervision will be exercised in the shops and not in the home. T h i s is only one facet of our problem, similar measures in other directions are equally required, satisfactory designs for kitchen utensils, construction of adequate guards for coal-burning fires and so on, and only by continued efforts to keep the importance of such matters before the public will action be brought about, but encouragement for the future m u s t b e taken f r o m the support given to the Fireguards Bill f r o m all sides of the House. With reference to ignition of clothing, the elimination of inflammable materials for children's clothing is of the utmost importance. Ftannellette is still procurable, it is cheap and therefore m u c h used. Cotton is the fabric found to be most c o m m o n l y the first one ignited in cases of burning clothing. It is stated to be technically possible to produce fireproof and flameproof materials but production on a large scale w o u l d be highly expensive thereby adding yet m o r e to the cost of maintenance of a family, unless the G o v e r n m e n t f a c e d the responsibility to accept a large part of the expense involved. Another instance where some responsibility of t h e housewife m i g h t be relieved is in the m e t h o d of packing of tablets c o m m o n l y in use in the home, chiefly the salicylate group and fersolate. T h e former are obtainable by all at little cost and used a great deal, the latter n o w increasing in distribution through clinics. T h e harassed m o t h e r with a headache takes two tablets of aspirin, puts the hottte back in the drawer or leaves it on the bed or table and so it gets into the hands of the toddler. Similarly w i t h ferso-
PUBLIC HEALTH, June, I953 late, it may be issued in a special bottle with a label printed in red, but T o m m y cannot read and m o t h e r has a m o m e n t a r y lapse. Some of the popular products are now being issued in pocket pack form, each tablet separately sealed. It is quite a feat to take one out of its packing and would take T o m m y so m u c h time that his activity would probably be discovered before m u c h h a r m had been done, in any case the n u m b e r swallowed w o u l d be limited. Aspro, E m p i r i n c o m p o u n d , dispensing packs of Disprin and some other products are already packed in this way at little appreciable additional cost, and I am informed the process could be easily extended. This, again, is outside the m o t h e r ' s province to achieve but would not such a procedure eliminate m u c h of our uncertain h u m a n frailty ? T o avoid the risk of true accidental suffocation education may be the present answer. T o warn the mothers of dangers connected with the feeding of infants and the sharing of beds and so on ; careful watch m u s t be kept on the possibility of new products set out to attract the m o t h e r containing some unforeseen danger as occurred with plastic bibs, and public attention drawn to t h e m as they arise. W h a t e v e r G o v e r n m e n t action m a y be taken it will be some time before it is in general application and in the m e a n t i m e the present system of advice m u s t be continued but it can in some respects be intensified. T h e B i r m i n g h a m Burning Accidents C o m m i t t e e ~ has p r o d u c e d a leaflet showing the types of fireguard which give real efficiency, probably the first approved list of such products, for the guidance of purchasers. T h i s is an experiment which m i g h t well be followed and taken into other fields, at the risk maybe o f incurring disapproval from the trade, but no matter. I n brief, m y argument is t h a t m a n y accidents to young c h i l d r e n in the h o m e could be avoided, some b y direct teaching on the hazards incurred in daily c o m m o n tasks, but that the onus of prevention should not be laid wholly on the m o t h e r : that public opinion m u s t be stimulated to demand local or national action to bring about measures t a ensure that goods available to the public should be so prepared and constructed as to give the m a x i m u m of safety and the m i n i m u m of inherent dangers in their use. T h i s is not an extension of spoon feeding and the removal of yet more responsibility from parents but a matter of c o m m o n sense and public c o n s c i e n c e : following the lead of K i n g E d w a r d V I I on tuberculosis, " If preventable, w h y not prevented ? "
T h e R o l e of the H e a l t h D e p a r t m e n t in P r e v e n t i o n of Home Accidents In various observations on accidents in the h o m e reference has been m a d e to the part which might be played by the Medical Officer of Health. I n the Report of the Chief Medical Officer of the M i n i s t r y in 1946 he said 1~ that " one cause of mortality and therefore presumably of ntorbidity that has not received the attention it merits is ' A c c i d e n t s in the H o m e . ' " In his report for 1949 u he wrote, " T h e reduction of h o m e accidents should f o r m an i m p o r t a n t part of m o d e r n preventive m e d i c i n e - - m e a s u r e s to p r e v e n t their future occurrence can provide a fruitful field of epidemiologieal work for the Medical Officer of H e a l t h . " The Medical Officer 1~ states, " injury to health and life f r o m physical agents becomes a fit subject for our attent i o n , " and m o r e recently the same journal xs said, " t h e staff of the Medical Officer of Health are in a position to contribute by homely and timely advice, in a m a n n e r which is not open to any other body of persons." It w o u l d therefore appear that no little respOnsibility is now being laid on to the health departments in this connection. Powers to undertake such work are given under the National Health Service Act, 1946, Section 28, in the words " shall include arrangements for the purpose of the prevention of illness and the p o w e r to contribute to any voluntary organisation formed for any purpose as aforesaid," and in the Local G o v e r n m e n t Act, 1948, Section t36, " a Local Authority may contribute towards the expenses of any body carrying
PUBLIC H E A L T H , June, I953 o n activities w i t h i n the area of t h a t a u t h o r i t y a n d of giving advice, i n f o r m a t i o n or o t h e r assistance to p e r s o n s r e s i d e n t therein." F o r t h e M e d i c a l Officer of H e a l t h to carry o u t these provisions b y w a y of r e c o m m e n d a t i o n t h a t c o n t r i b u t i o n s b e m a d e to n a t i o n a l or local v o l u n t a r y organisations a n d s u p p o r t for Local Safety C o m m i t t e e s to b e established is possibly t h e m o s t usual a n d t h e easiest course. T h i s does give the o p p o r t u n i t y to b r i n g the i m p o r t a n c e of t h e -matter before c o m m i t t e e s b u t is often n o t sufficiently stressed. L e c t u r e s m a y b e arranged, posters displayed, p a m p h l e t s d i s t r i b u t e d or c o - o p e r a t i o n given in H o m e Safety E x h i b i t i o n s ; a n d while agreeing t h a t some mass educational work of value m a y b e d o n e b y these m e a n s , especially if c o n t i n u o u s l y repeated, it does n o t a p p e a r to cover the whole field to w h i c h the M e d i c a l Officer of H e a l t h could direct his energies. T h e i m p o r t a n c e of direct personal t e a c h i n g is acknowledged to b e the keystone of child welfare. A m o t h e r m a y see safety posters o n t h e walls of h e r welfare centre for weeks, b u t she f r e q u e n t l y does n o t a p p l y t h e i r lessons to h e r o w n h o m e c r a f t . T h e visit of t h e h e a l t h visitor, district n u r s e or s a n i t a r y i n s p e c t o r m a y reveal u n g u a r d e d fires, tablets i n full view a n d r e a c h of children, a n d so on, a n d a t t e n t i o n d r a w n to t h e s e failures to m a i n t a i n safety in their o w n h o m e , b y a p e r s o n w h o s e advice is valued, will p r o b a b l y b e of m o r e lasting benefit. E v e n in well-regulated families these lapses o c c u r ; a n d m a k e a s t r o n g plea for t h e c o n t i n u a n c e of r o u t i n e h e a l t h visiting, despite o t h e r calls o n t h e h e a l t h visitors' time nowadays. Regard has to b e p a i d to t h e e n v i r o n m e n t of the child as well as to its physical a n d m e n t a l needs. M o r e specific direction on this aspect of h e a l t h visiting m i g h t be g i v e n b y Medical Officers of Health. F e w of us, I imagine, k n o w t h e real extent of injuries occurring in y o u n g c h i l d r e n i n t h e i r h o m e s in o u r o w n areas, a n d we t e n d to talk a b o u t accidents w i t h o u t facts to s u p p o r t o u r case. T h e r e is n e e d for full investigations ; into the exact cause of each accident, t h e type of m o t h e r , k i n d of h o m e , degree of m o r b i d i t y a n d so o n w h i c h m i g h t give us some c o m m o n factors on w h i c h a m o r e reliable estimation of the h a z a r d s of y o u n g c h i l d r e n could b e based, a n d a m o r e satisfactory solution in dealing w i t h t h e h u m a n factor reached. S u c h a s u r v e y w o u l d require the participation of hospitals, a n d general practitioners, coroners a n d police as well as all m e m b e r s of t h e h e a l t h d e p a r t m e n t staff, a n d could p r o b a b l y b e s t b e initiated b y the M e d i c a l Officer of Health. I n a different s p h e r e the M e d i c a l Officer of H e a l t h could take a lead in i n f l u e n c i n g p u b l i c o p i n i o n towards G o v e r n m e n t action for t h e p r o d u c t i o n of real safety h o m e e q u i p m e n t at reasonable costs w i t h t h e e l i m i n a t i o n of u n n e c e s s a r y risks : p e r h a p s w i t h sufficient p r e s s u r e f r o m the B r a n c h e s even the Society m i g h t be p e r s u a d e d to take u p some definite line of action. F o r t h e cases of s u d d e n d e a t h to w h i c h I have alluded little in t h e way of p r e v e n t i o n seems possible, b u t it is a f u n c t i o n of t h e M . & C.W. service to e n d e a v o u r to p r e v e n t u n d u e anxiety or c o n c e r n to m o t h e r s ; a n d e v e r y care s h o u l d b e t a k e n to e n s u r e t h a t m o t h e r s are spared lasting r e p r o a c h to t h e m s e l v e s for t h e d e a t h of t h e i r child f r o m m e c h a n i c a l suffocation w h e n in fact some disease was present. T h i s can only b e satisfactorily p r o v e d b y postmortem e x a m i n a t i o n a n d m e d i c a l officers s h o u l d exert .their influence o n H . M . C o r o n e r s to r e q u i r e s u c h an e x a m i n a tion in every case, w h i c h is n o t at p r e s e n t a u n i v e r s a l practice. T h i s cause is n o t w i t h o u t its difficulties, t h e M i n i s t r y of H e a l t h do n o t a p p e a r anxious to take this m a t t e r u p directly w i t h t h e Association of C o r o n e r s ; a n d it m a y again b e a c o n s u m m a t i o n to b e b r o u g h t a b o u t b y the action of t h e Society. Medical officers of H o u s i n g A u t h o r i t i e s m u s t accept responsibility for p r e s s i n g o n t h e i r councils the n e e d for adequate m e a s u r e s in safety in n e w houses, particularly in respect of guards for fires, a n d gas a n d electric installations, a n d could initiate schemes for loan of fireguards. W e are told t h a t m u c h bf t h e w o r k is b e i n g t a k e n f r o m
135 health departments. I t w o u l d s e e m t h a t t h e r e is m u c h i n this field still to b e explored. W e do n o t n o w expect m a n y c h i l d r e n to contract s m a l l p o x or d i p h t h e r i a , b u t we s p e n d m u c h t i m e a n d m o n e y to e n s u r e t h e i r p r o t e c t i o n in this respect. H o w m u c h m o r e likely is a child to suffer f r o m b u r n s or scalds a n d w h a t efforts are we m a k i n g for his p r o t e c t i o n on this score ? I h a v e e n d e a v o u r e d to s h o w in this p a p e r the e x t e n t of t h e p r o b l e m of accidents to the y o u n g child at h o m e ; c o m p a r a t i v e l y few of these are due to w h o l l y u n a v o i d a b l e causes. I h a v e p u t before y o u m y o p i n i o n t h a t t h e p r e v e n t i o n of some of t h e m o r e serious risks is n o t solely a m a t t e r of e d u c a t i o n or d i r e c t i o n of t h e p a r e n t s , b u t requires action outside the h o m e to eliminate to a greater degree t h e h u m a n element, b y e n s u r i n g t h a t efficient safeguards against t h e c o m m o n h a z a r d s can b e o b t a i n a b l e at r e a s o n able cost b y t h e general public. I have outlined the measures which might properly be t a k e n b y M e d i c a l Officers of H e a l t h t o w a r d s the safety of c h i l d r e n in t h e i r homes, a n d w h e n I say M e d i c a l Officers of H e a l t h I include t h e m a t e r n i t y a n d child welfare officers, w h o I anticipate w o u l d b e g i v e n a large p a r t of a n y a d d i tional w o r k i n this sphere. S p e a k i n g for m y colleagues I can surely say we w o u l d welcome even extra w o r k of this k i n d to free t h e children, for w h o m we feel a p e c u l i a r responsibility, f r o m t h e perils a n d d a n g e r s w h i c h b e s e t t h e m n o t in t h e n i g h t alone b u t w h i c h e n c o m p a s s t h e m t h r o u g h o u t t h e i r livelong day. REFERENCES
1 BOUCHER,C.A. (1952.) Mthly. Bull., Min. ofHlth, f-4P.H.L.S., I I , 2, 2 COLEBROOK, L. ~ V.
(1951.) A suggested national plea to reduce burning accidents. Lancet, 2, 579. 3 BOWDEN, KEITH. (1950.) Sudden death or alleged accidental suffocation in b a b i e s . Med. J. Aust., January 21st. * SWINSCOW, DOUGLAS. (1951.) So-called accidental mechanical suffocation of infants. Brit. Med..7., 2, 1004. British Standard. 1670 : 1951. British Standard. 1250 : pt. 2. 1946. 7 Housing Manual. (1949.) Sect. 175. 8 Hansard. March 14th, 1952. 9 Burning Accidents Committee, Birmingham. Advice on Fireguards. 10 ,, On the State of Public Health during Six Years of War." (19460 1l ,, On the State of the Public Health." (1949.) 12 The Medical Officer. Editorial. (October 27th, i951). 86, 165. 1~ Editorial (August 16th, 1952). 88, 67. THE SOCIETY OF MEDICAL OFFICERS OF HEALTH NOTICES EXTRAORDINARY A N D ORDINARY MEETINGS, SEPTEMBER, x7th , x9S 3 Preliminary notice is hereby given that an Extraordinary Meeting of the Society will be held at the L o n d o n School of Hygiene and Tropical Medicine on Thursday, September 17th next, at 8 p.m., at which a resolution will be put forward to effect the change of the present title of the Society to " T h e Society of Preventive Medicine." At 5.30 p.m. there will be an Ordinary Meeting at which the President for 1952-53 (Dr. Andrew Topping) will install Dr. C Metcalfe Brown as President for the session 1953-54 and the latter will deliver his Presidential Address. A sherry party will be given by the School after the meetings. S. R. BRAGG, Tavistock House, Administrative Officer. Tavistock Square, London, W.C:I. REFRESHER COURSE FOR COUNTY DISTRICT M.O.Hs. T h e County District M.O.H: Group is organising a refresher course to be held at the London School of Hygiene and Tropical Medicine from Thursday evening, September l'/th, to midday, Sunday, September 2Oth next. T h e opening meeting will be the Ordinary Meeting of the Society of which notice is given above. Full details will be published in the July issue of PUBLIC HEALTH. Preliminary applications should b e sent to the Administrative Officer, Society of M.O.H., Tavistock House~ Tavistock Square, London, W.C.1.
I3z HOW FAR ARE ACCIDENTS TO YOUNG CHILDREN AT HOME AVOIDABLE ? *
By E. CATHERINE MORRIS JONES, M.B., D.P.H.,
Senior Medical Officer, Maternity & Child Welfare, Gloucestershir e I n obtaining details for the A n n u a l Report of 1950 I was struck by the unduly high n u m b e r of children u n d e r one year w h o s e death was attributed to some kind of acci, dent ; and I felt that this topic, e x p a n d e d up to five years, might f o r m the basis of m y presidential talk. Since that time there has been a plethora of pamphlets, articles, and statements on this general subject of h o m e accidents, and it seemed that all the points I m i g h t have brought forward for your consideration had already been discussed by m u c h abler people. However, I decided to continue in m y purpose. T h e r e is an advantage in putting together the observations of the experts, which I have shamelessly done ; and if any excuse is needed for m y choice it is that the subject is " topical " ; and I can only hope t h a t if you have read the various articles you have long forgotten them. T h e extent of m y t h e m e is, firstly, to set out the scope of the p r o b l e m relating to young children ; secondly, to give a brief outline of the more c o m m o n accidents ; thirdly, to discuss whether they are in whole or in part avoidable ; and lastly, to envisage the place of the public health service in this matter. Scope I n the Monthly Bulletin of the M i n i s t r y of H e a l t h for January, 1952, Dr. Boucher 1 informs us that in E n g l a n d and Wales each year about 6,000 persons die as a result of domestic accidents, i.e., 46% of all fatal accidents. As h o m e accidents are not notifiable, t h e n u m b e r of non-fatal accidents cannot be accurately determined ; b u t an e s t i m a t e of a 4 % annual h o m e accident rate of the population' has been m a d e where such accidents are of sufficient severity to require hospital treatment. The n u m b e r of m i n o r aceidents is completely .unknown at the present time. O f the fatal accidents 20%, or approximately 1,200, occur in children u n d e r five, and in children between one and five a fatal h o m e accident is the third largest cause of death. Information on non-fatal accidents will sometimes be ascertained from hospital records, child welfare centre case sheets or in conversation with mothers, and in our own families, and it is apparent that the child in his first five years is particularly liable to hazards in the home. Apart from the distress caused to the family by death following an accident, there is the possibility of long stay in hospital with permanent disability or disfigurement, which may affect the outlook of the child. It m a y be that m i n o r accidents w i t h complete recovery are part of the child's normal adjustment to his e n v i r o n m e n t and as such are beneficial to his true education,. T h e p r o b l e m related to young children is therefore of a degree to merit special consideration. Causes W h a t are the risks inherent in the h o m e e n v i r o n m e n t ? T h e y are legion and impossible to enumerate in d e t a i l : burns due to ignition of clothing or playing with matches ; strangulation with a p r a m harness or between the bars of a cot ; scalding from the upsetting of some utensil concerned in that British Institution " t h e cup of t e a " ; swallowing of poisonous substances ; falls down u n g u a r d e d stairs, or cuts from untimely play with scissors or knives. Some injuries are of a very transitory nature but all such make up a large sum total of accidents. I do not propose to deal in detail with each type of misfortune but to select certain groups for m o r e exhaustive consideration.
Presidential Address to the West of England Branch, Society of M.O.H., Taunton, October 4th, 1952.
(1) Burns and Scalds T h e largest group of serious accidents to young children about which detailed information is available is that involving burns and scalds. W h e r e hospital treatment was necessitated the reports published in 1949 and 1951 by L. & V. Colebrook 2 g~ve a comprehensive picture ; 1,374 out of 2,000 consecutive cases of burns and scalds admitted to the B i r m i n g h a m A c c i d e n t Hospital were due to causes in the h o m e ; 737, or 53%~ occurred in children under five ; 435 o f the 650 scald cases (67%) and 302 of the 724 b u r n cases (41%); It w o u l d appear t h a t injury from scalding is therefore one o f the commonest risks for a child. Of these cases 63% were occasioned by the upsetting of containers of hot fluids : kettles, saucepans, teapots, tea-cups, etc. ; 17~o by falling into baths or buckets of hot water, and 20% in other ways. A m o n g these cases there w e r e three deaths. W e cannot compute the amount of family distress caused through such accidents but we know t h a t an average of 31 days' stay in hospital was involved. I n relation to the 302 cases of burns, 176 occurred as a result of direct or indirect contact with a domestic fire, electric, gas or coal, and that 149 of these fires w e r e u n g u a r d e d at the time of the accident. T h e remaining 126 cases were due to miscellaneous causes : burns from inflammable gases, bonfires, fireworks, hot fat, falling on hot metal or ashes, matches, etc. In 93 of all the cases clothing caught fire and the 12 deaths in the group were all associated with this fact. W i t h m o d e r n treatment burn patients do not often die to-day unless their injuries are extensive, and this is likely to be the case w h e n clothing catches fire. T h e risk to children f r o m heat, which is an essential utility in the home, is therefore not inconsiderable.
(2) Suffocation W e are all familiar with the death certificate of suffocation, sometimes due to swallowing of a foreign body as a balloon, to j a m m i n g of head between cot bars, to plastic bibs, to smothering by a cat, to overlaying in bed or to regurgitation and inhalation of food ; also sometimes alleged to be due to smothering by a soft cot pillow or bedclothes or to lying on the face in the cot, a n d are apt to consider these occurrences should n e v e r have happened. T h e average annual n u m b e r of deaths ascribed to accidental mechanical suffocation is about 600 a year. Such deaths have a peculiar poignancy, as they occur p r e d o m i n a n t l y in children u n d e r one year of age, and frequently to first children. M u c h distress is caused to a family in which such an event happens, often w i t h a lasting feeling of guilt of the mother or nurse responsible for the infant. In this connection I should like to draw your attention to articles by Keith Bowden 3 a n d Douglas Swinscow ~. T h e s e writers express the view that because a child is found dead in a cot face downwards or beneath the bedclothes the death should not ipso facto be attributed to accidental suffocation, but may be due to some undiscovered or unree0gnised disease. Cases are-quoted of children thought to be quite well even by trained observers dying suddenly during or following a feed, with or without vomiting occurring, and of instances in which, on careful consideration after the death, the parent remembers that the child had been unnaturally quiet or peevish for a period beforehand. Meticulous post-mortem examination-4n such cases revealed the p r e s e n c e of organic disease, acute interstitial myocarditis, acute nephritis, disease of ear and mastoid a n t r u m , b r o n c h o - p n e u m o n i a and other lung infections, which had been completely unsuspected. T h i s leads t h e m to believe that rapid changes may take place in body tissue in disease w h i c h m a y lead to sudden deaths in infants with little or no evidence of illness. T h e y do not deny that mechanical suffocation does take place ; .but consider that suffocation from inhalation of vomitus in cot, or due to covering with bedclothes, is a rarity in a healthy infant. M o s t infants w h e n they can m o v e freely t e n d to t u r n on to their faces in their cot, and even go u n d e r the clothes ; but a healthy baby can extricate himself f r o m this
PUBLIC H E A L T H , June, .t953 position w h e n h e wishes to do so, or cry o u t if h e c a n n o t free himself. S h o u l d a child w h o is suffering f r o m some disease w h i c h is r u n n i n g a swift course get into this position, he m a y well be expected to m a k e little s o u n d or effort i n his del3arture , a n d i n d e e d i n n o t all cases is the n o s e a n d m o u t h o c c l u d e d b y the b e d d i n g . T h e p r e s e n c e of v o m i t u s in the air pass ages alone is n o t evidence t h a t this was t h e sole cause of d e a t h for v o m i t i n g is a c o m m o n t e r m i n a l event in disease. I n 1945 post-mortems were carried out i n B i r m i n g h a m o n every case in w h i c h asphyxia was c o n s i d e r e d t h e possible cause of death, a n d o u t of 318 cases in only 24 was t h e asphyxia caused mechanically. S w i n s c o w has s h o w n t h a t the n u m b e r of certificates of deaths of suffocation of i n f a n t s " in b e d , " i.e., w i t h o t h e r people, has declined recently whereas those f r o m suffocation " in cot " or " b y food " have risen. T h e b u r d e n of b o t h writers is t h a t n o i n f a n t s ' d e a t h s h o u l d b e a t t r i b u t e d to suffocation unless t h e r e is cleat post-mortem evidence to s u p p o r t this view. (3) Poisoning T h e periodic o c c u r r e n c e of p o i s o n i n g of y o u n g c h i l d r e n is c o m m o n knowledge, s o m e t i m e s arising f r o m tablets issued to t h e m o t h e r b y a local a u t h o r i t y clinic. T h e giving of aspirin c o m p o u n d s , fersolate, etc., to a y o u n g e r child b y one only a little older as sweets, h a p p e n s almost daily, t h o u g h f o r t u n a t e l y is n o t i n v a r i a b l y fatal. T h e d r i n k i n g o f lethal liquids f r o m bottles left o n tables or t h o u g h t to b e j u s t out of r e a c h is a f r e q u e n t h a p p e n i n g in t h e h o m e . (4) Other Causes Falls. T h e s e do n o t so f r e q u e n t l y occur to y o u n g c h i l d r e n w h o are left to t h e i r explorations w i t h o u t u n d u e i n t e r ferences ; like a cat a child can achieve great feats of balance, b u t if startled a n d t h e i r sense of c o n c e n t r a t i o n a n d equilib r i u m are d i s t u r b e d a t u m b l e w i t h resulting bruises m a y follow. Cuts f r o m knives, scissors or b r o k e n glass a n d c h i n a m a y p r o d u c e f r i g h t o u t of all p r o p o r t i o n to t h e degree of t h e injury, b u t rarely p r o d u c e death. Electrocution f r o m faulty installations is b u t a snlall cause of i n j u r y to y o u n g children. T h e s e are b u t a few of c o n l r n o n daily occurrences.
Avoidance of Accidents T h e r e is a fallacy in the title of this paper. A c c o r d i n g to definition a n accident is an e v e n t w i t h o u t a p p a r e n t c a u s e - - a n u n f o r e s e e n e v e n t - - t h e r e f o r e strictly such events are u n a v o i d a b l e ; or m o r e p o p u l a r l y u n p r e v e n t a b l e . A n d t h e r e I could stop. B u t it is also defined as an u n i n t e n tional act, w h i c h is a definition m o r e applicable to t h e m a t t e r s we are c o n s i d e r i n g - - t h e act occasioned b y default r a t h e r t h a n b y design. S o m e c o m p l a c e n t l y declare t h a t " A c c i d e n t s will h a p p e n " : o n t h e o t h e r h a n d , it is c o m m o n parlance to say t h a t the e v e n t is m o s t often due to c a r e lessness, a n d w h e r e y o u n g c h i l d r e n are involved to t h e carelessness of t h e m o t h e r . A r e we fair in p u t t i n g the b l a m e for all injuries great a n d small o n t h e housewife ? T h e r e can b e ~few m o t h e r s w h o deliberately expose t h e i r c h i l d r e n to 'danger. S o m e are n o t sufficiently i n t e r e s t e d to take all m e a s u r e s to p r o t e c t t h e m a n d s o m e - - t h e larger n u m b e r - - w o u l d take all possible care b u t are i g n o r a n t of the d a n g e r spots in t h e i r h o m e s or are u n a b l e to p r o v i d e the essential safeguards. O t h e r s again will m a k e efforts to follow s u c h practices as t h e y m a y b e advised, a n d if this advice is i n a d e q u a t e or i n c o m p l e t e t h e y are given a sense of false security. W h e r e can action be t a k e n t h a t will reduce the c h a n c e of accidents ? It h a s b e e n d e m o n s t r a t e d b y m a n y people t h a t t h e risk of accidents is greater in o v e r c r o w d e d homes, b a d l y c o n s t r u c t e d houses, a n d a m o n g t h e lower i n c o m e groups. I n a series-of 50 cases of b u r n s in G l a s g o w 45 of the c h i l d r e n came from homes where there was: overcrowding and squalor, w h e r e the s t a n d a r d of h o m e - c r a f t was poor, a n d the m e n t a l capacity, a n d s o m e t i m e s t h e physical capacity, of t h e m o t h e r low. T h o s e w h o have d o n e m u c h work in this field tell us t h a t
z33 t h e m a i n w e a p o n in t h e a r m a m e n t a r i u m m u s t be e d u c a t i o n - - t a l k s , posters, d e m o n s t r a t i o n s to g r o u p s of all ages, c o m m e n c i n g w i t h c h i l d r e n at school. Will t h i s achieve t h e p u r p o s e ? Firstly, we m u s t b e careful w h a t we t e a c h as it is n o t e n o u g h to advise generally w i t h o u t specific directions. I n this c o n n e c t i o n consider t h e m a x i m advising m o t h e r s to h a v e a fireguard, i n C o l e b r o o k ' s series 26 of t h e b u r n injuries were i n cases w h e r e a fireguard Was present, b u t w h a t k i n d of a g u a r d ? T h e essentials of a t r u e g u a r d m u s t b e p o i n t e d at. T h e y m a y b e w a r n e d of the dangers f r o m containers of h o t l i q u i d s ; b u t t h e usual type of p a n o b t a i n a b l e at a reasonable cost h a s a p r o j e c t i n g handle, a n d m o s t kettles a n d all tea cups are top h e a v y a n d easily u p s e t ; n o t so b e e r mugs, a l t h o u g h t h e y are n o t d e s i g n e d for t h e use of c h i l d r e n ! M o d e r n design can p r o d u c e p a n s a n d kettles w h i c h are n o t top heavy, b u t t h e y are expensive, a n d s u c h d r a w b a c k s m u s t be b o r n e i n m i n d i n t h e advice given. E d u c a t i o n i n the h o m e is of greater value, t h e p o i n t i n g o u t to a m o t h e r in h e r o w n h o m e of s o m e f a u l t of e q u i p m e n t or practice will have a m o r e lasting effect t h a n a general discourse o n t h e dangers t h a t lurk i n houses, details of w h i c h m a y n o t b e t a k e n to h e a r t b y t h e i n d i v i d u a l . " I t n e v e r will h a p p e n to m e l " P e r h a p s t h e b e s t e d u c a t o r is t h e o c c u r r e n c e of a serious accident, n o t only to t h e family c o n c e r n e d b u t to those a r o u n d . F o l l o w i n g a r e c e n t case of d e a t h in o u r c o u n t y d u e to a child swallowing almost a w h o l e b o t t l e of aspirin, m o r e t h a n one m o t h e r , r e a d i n g of t h e h a p p e n i n g in t h e e v e n i n g paper, w e n t i m m e d i a t e l y to b e assured t h a t all s u c h n o x i o u s s u b s t a n c e s were well away f r o m t h e r e a c h of h e r o w n child. I t is rarely t h a t a serious a c c i d e n t occurs twice i n t h e same family f r o m t h e same cause. I a m n o t d e c r y i n g s p r e a d i n g the gospel of p r e v e n t i o n b y education, or t h e efforts of those e n g a g e d i n this work, b u t it is a slow process, often d i s r e g a r d e d b y those w h o n e e d it m o s t , a n d in m a n y cases has p o o r material to work on, a n d m e a n w h i l e the n u m b e r o f h o m e accidents has n o t decreased v e r y m u c h since 1943. Is t h e r e n o o t h e r way b y w h i c h some of t h e risks could b e r e d u c e d if n o t e n t i r e l y e l i m i n a t e d ? W h a t of t h e L a w ? T h e r e is legislation c o n c e r n i n g t h e p r o y i s i o n of fireguards in certain c i r c u m s t a n c e s w h e r e c h i l d r e n are involved, h u t we k n o w it is a law h o n o u r e d m o r e in t h e b r e a c h t h a n in t h e o b s e r v a n c e and, b e i n g so e x t e n sively disregarded, is of little value. W o u l d f u r t h e r legislation applied to p e r s o n s i n t h e i r h o m e s b e of m u c h avail w i t h o u t s u c h " s n o o p i n g " as w o u l d restrict t h e f r e e d o m of t h e h o m e ? Is n o t t h e n e e d n o w for action to be t a k e n outside t h e h o m e ? T h a t some regulations m i g h t well be m a d e has b e e n t h e view of v a r i o u s b o d i e s for some t i m e - - F e d e r a t i o n of W o m e n ' s Institutes, N a t i o n a l Council of W o m e n , a n d so on. C o l e b r o o k h a s d r a w n u p a n a t i o n a l plan for t h e r e d u c t i o n of b u r n i n g accidents a n d t h e I n t e r - d e p a r t m e n t a l C o m m i t t e e set u p b y t h e H o m e Secretary in 1947 has b e e n w o r k i n g to t h e same end. T h e s e efforts r e s u l t e d in t h e B u l l a r d F i r e g u a r d Bill, w h i c h received its t h i r d r e a d i n g in J u n e , 1952. T h e B~itish S t a n d a r d s I n s t i t u t i o n 5, 6 has c o n s i d e r e d s t a n d a r d safety specifications for electric fires, a n d a m i n i m u m s t a n d a r d of safety, a satisfactory s t a n d a r d of m e c h a n i c a l a n d electrical construcfion~ h a s b e e n set out. E v e n w i t h s u c h i m p r o v e m e n t s as these m a y have it is specifically stated t h a t " t h e p r e s e n t s t a n d a r d is restricted t o p r o v i d i n g p r o t e c t i o n to p e r s o n s f r o m accidents s u c h as m a y arise t h r o u g h negligence a n d t h o u g h t l e s s n e s s o n t h e p a r t of able a d u l t s - t h e y are n o t suitable w i t h o u t f u r t h e r p r o t e c t i o n for use in r o o m s occupied b y u n a t t e n d e d y o u n g c h i l d r e n " : so o u r p r o b l e m is n o t yet m e t in full. Similar s t a n d a r d s have b e e n laid d o w n for gas fires, w i t h t h e same provisos. B r i t i s h S t a n d a r d s set u p only a code of practice w h i c h is n o t c o m p u l s o r y o n m a n u f a c t u r e r s unless m a d e so b y law, a n d a f u r t h e r p o i n t arises. Articles c o n s t r u c t e d i n accordance w i t h t h e s e specifications are expensive, a large p a r t of t h e cost b e i n g p u r c h a s e tax, w h i c h is a p p r o p r i a t e d b y t h e G o v e r n m e n t . A s t a n d a r d type of fire m a y cost s (s P.T.). Is it u n r e a s o n a b l e to ask t h a t p u r c h a s e tax s h o u l d b e r e m o v e d f r o m articles for use in h o m e s w h e r e
I34 there are y o u n g children, and where their safety is of p a r a m o u n t importance. A n analogy with such a suggestion is to be found in industry where protective clothing is free of purchase tax. Also in relation to guarding of coal fires there are m a n y types of guard on the market ranging in price f r o m 9s. to 35s., but the Safety value does not always bear a relation to the cost. Some of the fastenings are so inadequate they can be easily u n d o n e by an active toddler and some have none at all. A great m a n y require removal for refuelling of the fire and u n d e r pressure of her duties the mother m a y not i m m e d i a t e l y replace the guard. People are accustomed these days to expect that the goods offered for sale are guaranteed for their purpose. T h e y do not question the safety of a p o u n d of sausages or a pint bottle of milk, but legislation has been r e q u i r e d to reach this stage. M u c h danger m a y be caused by the use of faulty e q u i p m e n t bought on account of its cheaper cost and with purchaser unaware of the absence of real safety. Manufacturers and retailers .supply the current demand, and unless a demand is made for a safe article the cheaper faulty risk-carrying one will gain the day. T h e Housing Manual, 19497 draws attention to the need for ensuring that proper fixtures for securing fireguards are provided in n e w houses but this is not always carried out. T h e provision of suitable fixtures involves little additional cost at the time of construction of the house but the lack of it m a y result in serious damage to the children. A n d w h y stop at fixtures ? Cannot Local Authorities make provision w h e r e b y adequate fireguards can be loaned for hire at a charge ? T h i s is done in E d i n b u r g h and is a useful lead for other authorities. It m i g h t even be possible where there are children u n d e r five years to arrange for an approved guard to be purchased f r o m a retailer at cost price or less, the balance of the full purchase price being paid by the Local Authority. T h e Bill to which I have previously referred is the H e a t ing Appliances (Fireguards) Bill s brought forward by a private m e m b e r , Mr. Bullard. T h e purpose is to prevent the sale in shops of electric and gas fires and oil stoves unless they are fitted with an adequate fireguard. T h e Bill is n o w on t h e Statute Book and the making of the date on which the regulations come into force and the fixing of standards will be laid down in due course and m a y welt prove one of the most important advances in which avoidance of bumir/g accidents will be brought abouL A n y official supervision will be exercised in the shops and not in the home. T h i s is only one facet of our problem, similar measures in other directions are equally required, satisfactory designs for kitchen utensils, construction of adequate guards for coal-burning fires and so on, and only by continued efforts to keep the importance of such matters before the public will action be brought about, but encouragement for the future m u s t b e taken f r o m the support given to the Fireguards Bill f r o m all sides of the House. With reference to ignition of clothing, the elimination of inflammable materials for children's clothing is of the utmost importance. Ftannellette is still procurable, it is cheap and therefore m u c h used. Cotton is the fabric found to be most c o m m o n l y the first one ignited in cases of burning clothing. It is stated to be technically possible to produce fireproof and flameproof materials but production on a large scale w o u l d be highly expensive thereby adding yet m o r e to the cost of maintenance of a family, unless the G o v e r n m e n t f a c e d the responsibility to accept a large part of the expense involved. Another instance where some responsibility of t h e housewife m i g h t be relieved is in the m e t h o d of packing of tablets c o m m o n l y in use in the home, chiefly the salicylate group and fersolate. T h e former are obtainable by all at little cost and used a great deal, the latter n o w increasing in distribution through clinics. T h e harassed m o t h e r with a headache takes two tablets of aspirin, puts the hottte back in the drawer or leaves it on the bed or table and so it gets into the hands of the toddler. Similarly w i t h ferso-
PUBLIC HEALTH, June, I953 late, it may be issued in a special bottle with a label printed in red, but T o m m y cannot read and m o t h e r has a m o m e n t a r y lapse. Some of the popular products are now being issued in pocket pack form, each tablet separately sealed. It is quite a feat to take one out of its packing and would take T o m m y so m u c h time that his activity would probably be discovered before m u c h h a r m had been done, in any case the n u m b e r swallowed w o u l d be limited. Aspro, E m p i r i n c o m p o u n d , dispensing packs of Disprin and some other products are already packed in this way at little appreciable additional cost, and I am informed the process could be easily extended. This, again, is outside the m o t h e r ' s province to achieve but would not such a procedure eliminate m u c h of our uncertain h u m a n frailty ? T o avoid the risk of true accidental suffocation education may be the present answer. T o warn the mothers of dangers connected with the feeding of infants and the sharing of beds and so on ; careful watch m u s t be kept on the possibility of new products set out to attract the m o t h e r containing some unforeseen danger as occurred with plastic bibs, and public attention drawn to t h e m as they arise. W h a t e v e r G o v e r n m e n t action m a y be taken it will be some time before it is in general application and in the m e a n t i m e the present system of advice m u s t be continued but it can in some respects be intensified. T h e B i r m i n g h a m Burning Accidents C o m m i t t e e ~ has p r o d u c e d a leaflet showing the types of fireguard which give real efficiency, probably the first approved list of such products, for the guidance of purchasers. T h i s is an experiment which m i g h t well be followed and taken into other fields, at the risk maybe o f incurring disapproval from the trade, but no matter. I n brief, m y argument is t h a t m a n y accidents to young c h i l d r e n in the h o m e could be avoided, some b y direct teaching on the hazards incurred in daily c o m m o n tasks, but that the onus of prevention should not be laid wholly on the m o t h e r : that public opinion m u s t be stimulated to demand local or national action to bring about measures t a ensure that goods available to the public should be so prepared and constructed as to give the m a x i m u m of safety and the m i n i m u m of inherent dangers in their use. T h i s is not an extension of spoon feeding and the removal of yet more responsibility from parents but a matter of c o m m o n sense and public c o n s c i e n c e : following the lead of K i n g E d w a r d V I I on tuberculosis, " If preventable, w h y not prevented ? "
T h e R o l e of the H e a l t h D e p a r t m e n t in P r e v e n t i o n of Home Accidents In various observations on accidents in the h o m e reference has been m a d e to the part which might be played by the Medical Officer of Health. I n the Report of the Chief Medical Officer of the M i n i s t r y in 1946 he said 1~ that " one cause of mortality and therefore presumably of ntorbidity that has not received the attention it merits is ' A c c i d e n t s in the H o m e . ' " In his report for 1949 u he wrote, " T h e reduction of h o m e accidents should f o r m an i m p o r t a n t part of m o d e r n preventive m e d i c i n e - - m e a s u r e s to p r e v e n t their future occurrence can provide a fruitful field of epidemiologieal work for the Medical Officer of H e a l t h . " The Medical Officer 1~ states, " injury to health and life f r o m physical agents becomes a fit subject for our attent i o n , " and m o r e recently the same journal xs said, " t h e staff of the Medical Officer of Health are in a position to contribute by homely and timely advice, in a m a n n e r which is not open to any other body of persons." It w o u l d therefore appear that no little respOnsibility is now being laid on to the health departments in this connection. Powers to undertake such work are given under the National Health Service Act, 1946, Section 28, in the words " shall include arrangements for the purpose of the prevention of illness and the p o w e r to contribute to any voluntary organisation formed for any purpose as aforesaid," and in the Local G o v e r n m e n t Act, 1948, Section t36, " a Local Authority may contribute towards the expenses of any body carrying
PUBLIC H E A L T H , June, I953 o n activities w i t h i n the area of t h a t a u t h o r i t y a n d of giving advice, i n f o r m a t i o n or o t h e r assistance to p e r s o n s r e s i d e n t therein." F o r t h e M e d i c a l Officer of H e a l t h to carry o u t these provisions b y w a y of r e c o m m e n d a t i o n t h a t c o n t r i b u t i o n s b e m a d e to n a t i o n a l or local v o l u n t a r y organisations a n d s u p p o r t for Local Safety C o m m i t t e e s to b e established is possibly t h e m o s t usual a n d t h e easiest course. T h i s does give the o p p o r t u n i t y to b r i n g the i m p o r t a n c e of t h e -matter before c o m m i t t e e s b u t is often n o t sufficiently stressed. L e c t u r e s m a y b e arranged, posters displayed, p a m p h l e t s d i s t r i b u t e d or c o - o p e r a t i o n given in H o m e Safety E x h i b i t i o n s ; a n d while agreeing t h a t some mass educational work of value m a y b e d o n e b y these m e a n s , especially if c o n t i n u o u s l y repeated, it does n o t a p p e a r to cover the whole field to w h i c h the M e d i c a l Officer of H e a l t h could direct his energies. T h e i m p o r t a n c e of direct personal t e a c h i n g is acknowledged to b e the keystone of child welfare. A m o t h e r m a y see safety posters o n t h e walls of h e r welfare centre for weeks, b u t she f r e q u e n t l y does n o t a p p l y t h e i r lessons to h e r o w n h o m e c r a f t . T h e visit of t h e h e a l t h visitor, district n u r s e or s a n i t a r y i n s p e c t o r m a y reveal u n g u a r d e d fires, tablets i n full view a n d r e a c h of children, a n d so on, a n d a t t e n t i o n d r a w n to t h e s e failures to m a i n t a i n safety in their o w n h o m e , b y a p e r s o n w h o s e advice is valued, will p r o b a b l y b e of m o r e lasting benefit. E v e n in well-regulated families these lapses o c c u r ; a n d m a k e a s t r o n g plea for t h e c o n t i n u a n c e of r o u t i n e h e a l t h visiting, despite o t h e r calls o n t h e h e a l t h visitors' time nowadays. Regard has to b e p a i d to t h e e n v i r o n m e n t of the child as well as to its physical a n d m e n t a l needs. M o r e specific direction on this aspect of h e a l t h visiting m i g h t be g i v e n b y Medical Officers of Health. F e w of us, I imagine, k n o w t h e real extent of injuries occurring in y o u n g c h i l d r e n i n t h e i r h o m e s in o u r o w n areas, a n d we t e n d to talk a b o u t accidents w i t h o u t facts to s u p p o r t o u r case. T h e r e is n e e d for full investigations ; into the exact cause of each accident, t h e type of m o t h e r , k i n d of h o m e , degree of m o r b i d i t y a n d so o n w h i c h m i g h t give us some c o m m o n factors on w h i c h a m o r e reliable estimation of the h a z a r d s of y o u n g c h i l d r e n could b e based, a n d a m o r e satisfactory solution in dealing w i t h t h e h u m a n factor reached. S u c h a s u r v e y w o u l d require the participation of hospitals, a n d general practitioners, coroners a n d police as well as all m e m b e r s of t h e h e a l t h d e p a r t m e n t staff, a n d could p r o b a b l y b e s t b e initiated b y the M e d i c a l Officer of Health. I n a different s p h e r e the M e d i c a l Officer of H e a l t h could take a lead in i n f l u e n c i n g p u b l i c o p i n i o n towards G o v e r n m e n t action for t h e p r o d u c t i o n of real safety h o m e e q u i p m e n t at reasonable costs w i t h t h e e l i m i n a t i o n of u n n e c e s s a r y risks : p e r h a p s w i t h sufficient p r e s s u r e f r o m the B r a n c h e s even the Society m i g h t be p e r s u a d e d to take u p some definite line of action. F o r t h e cases of s u d d e n d e a t h to w h i c h I have alluded little in t h e way of p r e v e n t i o n seems possible, b u t it is a f u n c t i o n of t h e M . & C.W. service to e n d e a v o u r to p r e v e n t u n d u e anxiety or c o n c e r n to m o t h e r s ; a n d e v e r y care s h o u l d b e t a k e n to e n s u r e t h a t m o t h e r s are spared lasting r e p r o a c h to t h e m s e l v e s for t h e d e a t h of t h e i r child f r o m m e c h a n i c a l suffocation w h e n in fact some disease was present. T h i s can only b e satisfactorily p r o v e d b y postmortem e x a m i n a t i o n a n d m e d i c a l officers s h o u l d exert .their influence o n H . M . C o r o n e r s to r e q u i r e s u c h an e x a m i n a tion in every case, w h i c h is n o t at p r e s e n t a u n i v e r s a l practice. T h i s cause is n o t w i t h o u t its difficulties, t h e M i n i s t r y of H e a l t h do n o t a p p e a r anxious to take this m a t t e r u p directly w i t h t h e Association of C o r o n e r s ; a n d it m a y again b e a c o n s u m m a t i o n to b e b r o u g h t a b o u t b y the action of t h e Society. Medical officers of H o u s i n g A u t h o r i t i e s m u s t accept responsibility for p r e s s i n g o n t h e i r councils the n e e d for adequate m e a s u r e s in safety in n e w houses, particularly in respect of guards for fires, a n d gas a n d electric installations, a n d could initiate schemes for loan of fireguards. W e are told t h a t m u c h bf t h e w o r k is b e i n g t a k e n f r o m
135 health departments. I t w o u l d s e e m t h a t t h e r e is m u c h i n this field still to b e explored. W e do n o t n o w expect m a n y c h i l d r e n to contract s m a l l p o x or d i p h t h e r i a , b u t we s p e n d m u c h t i m e a n d m o n e y to e n s u r e t h e i r p r o t e c t i o n in this respect. H o w m u c h m o r e likely is a child to suffer f r o m b u r n s or scalds a n d w h a t efforts are we m a k i n g for his p r o t e c t i o n on this score ? I h a v e e n d e a v o u r e d to s h o w in this p a p e r the e x t e n t of t h e p r o b l e m of accidents to the y o u n g child at h o m e ; c o m p a r a t i v e l y few of these are due to w h o l l y u n a v o i d a b l e causes. I h a v e p u t before y o u m y o p i n i o n t h a t t h e p r e v e n t i o n of some of t h e m o r e serious risks is n o t solely a m a t t e r of e d u c a t i o n or d i r e c t i o n of t h e p a r e n t s , b u t requires action outside the h o m e to eliminate to a greater degree t h e h u m a n element, b y e n s u r i n g t h a t efficient safeguards against t h e c o m m o n h a z a r d s can b e o b t a i n a b l e at r e a s o n able cost b y t h e general public. I have outlined the measures which might properly be t a k e n b y M e d i c a l Officers of H e a l t h t o w a r d s the safety of c h i l d r e n in t h e i r homes, a n d w h e n I say M e d i c a l Officers of H e a l t h I include t h e m a t e r n i t y a n d child welfare officers, w h o I anticipate w o u l d b e g i v e n a large p a r t of a n y a d d i tional w o r k i n this sphere. S p e a k i n g for m y colleagues I can surely say we w o u l d welcome even extra w o r k of this k i n d to free t h e children, for w h o m we feel a p e c u l i a r responsibility, f r o m t h e perils a n d d a n g e r s w h i c h b e s e t t h e m n o t in t h e n i g h t alone b u t w h i c h e n c o m p a s s t h e m t h r o u g h o u t t h e i r livelong day. REFERENCES
1 BOUCHER,C.A. (1952.) Mthly. Bull., Min. ofHlth, f-4P.H.L.S., I I , 2, 2 COLEBROOK, L. ~ V.
(1951.) A suggested national plea to reduce burning accidents. Lancet, 2, 579. 3 BOWDEN, KEITH. (1950.) Sudden death or alleged accidental suffocation in b a b i e s . Med. J. Aust., January 21st. * SWINSCOW, DOUGLAS. (1951.) So-called accidental mechanical suffocation of infants. Brit. Med..7., 2, 1004. British Standard. 1670 : 1951. British Standard. 1250 : pt. 2. 1946. 7 Housing Manual. (1949.) Sect. 175. 8 Hansard. March 14th, 1952. 9 Burning Accidents Committee, Birmingham. Advice on Fireguards. 10 ,, On the State of Public Health during Six Years of War." (19460 1l ,, On the State of the Public Health." (1949.) 12 The Medical Officer. Editorial. (October 27th, i951). 86, 165. 1~ Editorial (August 16th, 1952). 88, 67. THE SOCIETY OF MEDICAL OFFICERS OF HEALTH NOTICES EXTRAORDINARY A N D ORDINARY MEETINGS, SEPTEMBER, x7th , x9S 3 Preliminary notice is hereby given that an Extraordinary Meeting of the Society will be held at the L o n d o n School of Hygiene and Tropical Medicine on Thursday, September 17th next, at 8 p.m., at which a resolution will be put forward to effect the change of the present title of the Society to " T h e Society of Preventive Medicine." At 5.30 p.m. there will be an Ordinary Meeting at which the President for 1952-53 (Dr. Andrew Topping) will install Dr. C Metcalfe Brown as President for the session 1953-54 and the latter will deliver his Presidential Address. A sherry party will be given by the School after the meetings. S. R. BRAGG, Tavistock House, Administrative Officer. Tavistock Square, London, W.C:I. REFRESHER COURSE FOR COUNTY DISTRICT M.O.Hs. T h e County District M.O.H: Group is organising a refresher course to be held at the London School of Hygiene and Tropical Medicine from Thursday evening, September l'/th, to midday, Sunday, September 2Oth next. T h e opening meeting will be the Ordinary Meeting of the Society of which notice is given above. Full details will be published in the July issue of PUBLIC HEALTH. Preliminary applications should b e sent to the Administrative Officer, Society of M.O.H., Tavistock House~ Tavistock Square, London, W.C.1.