to meet urgently needed additions to their accommodation. The recent epidemics of scarlet fever and diphtheria have in certain instances found Isolation Hospital Authorities quite unprepared to meet the demand for accommodation. Some of them have endeavoured to cope with the situation either by overcrowding the wards of their hospitals or by improvising temporary additions in the shape of wood or iron. hutments quickly erected. Such hasty improvisations are usually expensive both in prime cost and in subsequent upkeep, and are unsatisfactory in working.

A number of Authorities have prepared schemes for the future provision of accommodation for infectious diseases, and have carried their proposals to the point of selecting a suitable site and preparing, in consultation with the Department, detailed plans and estimates, so that the work of construction may proceed without delay as soon as the cost of building and financial conditions generally permit. In all these cases the Department have endeavoured to promote joint action between neighbouring Authorities, in order to avoid the multiplication of small independent hospitals.

During the financial year 1921-22 loans amounting to £252,996 were sanctioned for the provision of isolation hospitals, mortuaries, cleansing and disinfecting stations, and ambulances. Of this total a sum of £198,000 was in respect of the purchase by the Metropolitan Asylums Board of the Homerton Institution belonging to the City of London Guardians, with a view to extending the accommodation available at the Eastern Fever Hospital, which immediately adjoins the former Institution.

PORT SANITARY ADMINISTRATION.

During the year the survey of the coast line of England and Wales was continued, and the efforts of the Department have been directed to securing such improvements in port sanitary administration as the reports of their Medical Officers have shown to be essential to efficiency. Most of the Port and Riparian Sanitary Authorities concerned have substantially agreed to carry out the Department's recommendations, but in four cases the Authorities were not prepared to take the necessary measures to bring their administration up to a reasonable standard of efficiency, and accordingly it was found necessary to withhold payment of the Exchequer grant in aid of the expenditure of those Authorities. In this connection it is important to bear in mind that not only is the health of this country dependent upon an efficient system of port sanitary administration, but also the prosperity of British shipping, which rests in no small measure upon the freedom of our Ports from such dangerous diseases as plague, cholera, typhus fever, etc.

During the financial year 1921-22 grants amounting to £39,232 were paid by the Department in aid of the expenses of Port and Riparian Sanitary Authorities.

The reports of the Medical Officers of the Department indicated that there was considerable uncertainty in the minds of the smaller Riparian Sanitary Authorities and their Officers as to the extent of their powers and duties with regard to the sanitary inspection of shipping. Accordingly a circular was issued on the 25th July, 1921, pointing out that for the purposes of the provisions of the Public Health Acts relating to nuisances and infectious diseases these Authorities have the same jurisdiction over vessels within their Districts as they have with regard to houses.

MEDICAL INSPECTION OF ALIENS.

The Department have continued to supervise the medical inspection of aliens at the Ports in this country which are approved by the Secretary of State for the landing of aliens, but the volume of the alien traffic entering these Ports is still much smaller than before the War. Additional instructions for the guidance of the Medical Inspectors of aliens were issued in 1921, dealing more particularly with the inspection of transmigrants, and the procedure to be adopted in the case of transmigrants found to be in a verminous condition or suspected to be suffering from trachoma, favus, etc. Arrangements have been made for the cleansing and disinfection, at the cost of the shipping company concerned, of any transmigrant found to be verminous, and for the strict surveillance by the shipping company of any transmigrant suspected to be suffering from trachoma, etc., and his prompt removal from this country on confirmation of the diagnosis.

During the financial year 1921-22, sums amounting to £7,965 were paid to Port and Riparian Sanitary Authorities in reimbursement of their expenditure on the medical inspection of aliens.

Maternity and Child Welfare.
GENERAL.

The steady progress which has been made since the work was first started has necessarily been retarded during the year under review by the urgent need for economy in local and national expenditure. In the circular which was addressed to Local Authorities on the subject of economy at the beginning of 1921, it was stated that the policy for the present must be to restrict expenditure to what is immediately necessary in the interest of public health, and this opinion has since been endorsed by the Committee on National Expenditure, who, while recognising the value of the objects aimed at by the grant-aided public health services generally, have in substance recommended that the contribution of the State, in 1922-23 at any rate, should not be above the figure provided for the financial year 1921-22. At the same time they express the hope, which there is reason to believe is being realised, that with falling prices and the greatly increased incentive to economy, the Authorities concerned will be able still further to increase their beneficial work.

GRANTS.

Following this recommendation, and pending a decision as to the future basis of grant, the Government decided, subject to Parliamentary sanction, to allocate such amounts from public funds during 1922-23 as would enable the existing standard of provision in the public health services to be maintained, and-it was hoped-some moderate development to be undertaken in directions considered to be essential on grounds of public health. Estimates in some detail of their anticipated expenditure on Maternity and Child Welfare in 1922-23 were obtained from the Local Authorities concerned, and a review was undertaken by the Department of the existing expenditure of the Authorities and their forecast of requirements for the next financial year, taking into account, among other considerations, the factor of falling prices. The Local Authorities were then informed of the maximum net expenditure during 1922-23 in respect of which grant would be paid.

The Maternity and Child Welfare grant distributed by the Department in 1921-22 amounted to £1,113,922*, of which £891,996 was paid to Local Authorities and £221,926 to voluntary societies. The grant is 50 per cent. of the approved net expenditure on purposes included in the regulations governing its distribution.

The net expenditure of Local Authorities during the year 1920-21 may be allocated among its various purposes as follows:

Home Helps..

58,160

4.1

Establishment and Miscellaneous Expenses

The grant to voluntary agencies is calculated on the net expenditure during the previous year after deducting contributions by Local Authorities and payments by or on behalf of patients or inmates, and in the year 1921-22 was distributed as follows:

Midwifery..
Centres

Day Nurseries

Homes and Hospitals

-

£

36,394

57,123

35,457

92,952

Some general particulars with regard to the work included under these headings are given below.

MEDICAL OFFICERS.

The whole of England is now covered, more or less completely, by schemes for Maternity and Child Welfare carried out by Local Authorities, which are in London the Metropolitan Borough Councils, in County Boroughs the Town Councils, and elsewhere the County Councils, except in about 280 County Districts, chiefly the larger nonCounty Boroughs and Urban Districts, in which the work is in the hands of the local Councils. It is part of the duty of the Medical Officer of Health of the Local Authority to supervise the Maternity and Child Welfare scheme, but the executive medical work in connection with it is usually carried out either by whole-time Medical Officers of the Local Authority or by general practitioners. The Department have in the past urged the Council of every County and of every County Borough and Metropolitan Borough to appoint an Assistant Medical Officer, preferably a woman, with special aptitude and experience, to supervise and assist in the work under the direction of the Medical Officer of Health, and 93 Local Authorities now have one or more Assistant Medical Officers for this purpose. The work of

* These and the other statistics in this section of the Report as to Maternity and Child Welfare relate to England only, except where otherwise stated.

such an officer is not necessarily confined to Maternity and Child Welfare, and in fact is very often combined with other duties such as the medical inspection of school children.

HEALTH VISITORS.

The sufficiency of the health visiting service varies considerably in different districts. The number of persons engaged in this work was increased during the year by 163, and the total number of women so acting on the 31st March, 1922, was 3,378. Of these, 2,328 gave their whole time to Maternity and Child Welfare work or to similar public appointments, such as that of School Nurse, Tuberculosis Visitor, etc., while 1,050 were District Nurses employed by Nursing Associations. Approximately the equivalent of the whole time of 1,660 women was devoted to health visiting at the end of the year.

Of the 3,378 women acting as Health Visitors, about 74 per cent. (including practically all the District Nurses) are trained midwives, and about 67 per cent. are fully trained nurses. Most Health Visitors have more than one of the qualifications hitherto regarded as fitting a woman to act as a Health Visitor. A number of women have now obtained the certificate prescribed by the regulations made by the Board of Education in 1919 for the training of Health Visitors, and a memorandum is being issued urging Local Authorities to give preference to such candidates in appointing Health Visitors.

MIDWIVES.

Of the 48,618 women on the Midwives Roll (covering the whole of England and Wales), 12,052 gave notice of intention to practise as midwives in 1921. Eighty-two per cent. of the total on the Roll are now certificated.

In 1920, the last year for which figures are available, the percentage of births notified by midwives was 47.7 in London, 66.9 in the County Boroughs, and 47-1 in the Counties.

The Department have continued to encourage Local Authorities to secure a complete service of competent midwives for their districts. In Urban Districts it is sometimes necessary for the Local Authority to contribute to an existing institution employing a midwife, or to pay or guarantee the salary of a competent midwife for an area in which a midwife in independent practice cannot make an adequate living. The chief difficulty, however, arises in sparsely populated rural areas, where it is generally impossible for a midwife to maintain herself by independent practice owing to the small number of cases occurring within her reach. In such areas the midwifery service is generally provided by District Nursing Associations, organised and assisted by County Nursing Associations, to which as a rule they are affiliated, and the midwives employed by them act also as District Nurses. In many counties they also undertake health visiting, school nursing, and other health services for the County Council.

Over 100 new District Nursing Associations were started in England during 1921, and only 12 of the existing Associations ceased work. Of the rural population of England 71 per cent. is now provided with the services of a trained midwife. On a rough estimate, 1,400 more District Nursing Associations are needed to provide a complete service in Rural Districts, and it is hoped that as financial circumstances improve these Associations will gradually be established.

NURSES.

Grant under the Maternity and Child Welfare Regulations is payable in respect of the home nursing of maternity cases and for certain infectious diseases in young children, such as measles, whooping cough, epidemic diarrhoea, poliomyelitis and ophthalmia neonatorum. About 140 Local Authorities have contracted with the local District Nursing Associations to provide this service, while others have authorised their Medical Officer of Health to employ a nurse when necessary. In a few cases such nursing is undertaken by the Health Visitor, while in some of the larger districts a special staff of nurses is engaged by the Council for this work. Some of these nurses have received special training at an eye hospital to enable them to deal with cases of ophthalmia

neonatorum.

CENTRES.

The Maternity and Infant Welfare Centre exists primarily for the preventive work of giving medical advice to expectant and nursing mothers as to the means by which they and their children may best be kept in health, and occupies a place of considerable importance in every scheme of Maternity and Child Welfare. Until recently the number of Centres in the country was increasing very rapidly, but owing to the financial position progress has now slowed down.

A Centre may be established and maintained either by a Local Authority or by a voluntary body. There are at the present time about 1,870 Maternity and Infant Welfare Centres in England, of which some 690 are maintained by voluntary agencies. Many of the latter receive financial assistance from the Local Authority; this tends to secure that close co-operation between the two bodies which is essential to the complete success of a general scheme for Maternity and Child. Welfare.

The Department have in the past encouraged the inclusion within. the scope of the work of a Centre, whenever possible, of dental treatment for expectant and nursing mothers. The number of Centres

making arrangements for dental treatment is now 232. Many Local Authorities and voluntary agencies have also made arrangements for the treatment of enlarged tonsils, adenoids, and other ailments of children. Treatment is also provided for expectant and nursing. mothers at a large number of Centres.

The Trustees of the Carnegie United Kingdom Trust have made a generous gift of £100,000 for the purpose of providing model Maternity and Infant Welfare Centres at a cost of £25,000 each in the County Boroughs of Liverpool and Birmingham, the Metropolitan Borough of Shoreditch and the Urban District of Rhondda. It is a condition of the gift that the Local Authority shall maintain the Centre, and in view of the restrictions on the amount of grant available for Maternity and Child Welfare the Department were unable to make a definite promise of grant in aid of the maintenance of these institutions until estimates of expenditure on Maternity and Child Welfare in 1922-23 had been received and examined. It is satisfactory to record that the margin of public money available for this service has been found to admit of assistance being promised towards the maintenance of these institutions, and steps are now being taken to establish them.