The Medical Officer of Health for Glasgow, through the courtesy of a firm of manufacturers at Rutherglen, obtained samples of flock used in the manufacture of bedding and found that flock made from material which had not been in use as clothing showed on analysis higher amounts of chlorine than is permissible in flock obtained from material which has been in use as clothing. As far as he has observed no supplementary test is applied to show whether or not the chlorine has been derived from inorganic sources. Chlorine, of course, may be an indication of human pollution, or it may be derived from inorganic sources and so may be innocuous. An English appeal case in 1912 decided that rags which showed high chlorine content must be considered as coming within the terms of the Act, whether the rags were of new or of worn material. A Glasgow prosecution, however, in 1920 was unsuccessful. The case was dismissed on the ground that it had not been proved that the material sold was rag flock within the meaning of the Act, although it contained 80 parts of chlorine in place of the standard of 30. The rag flock in question had been obtained from new material. We have this question at present under consideration.

Maternity and Child Welfare.

CHILDREN UNDER 5 YEARS-NUMBERS AND MORTALITY.

The population of Scotland at Census 1921 was 4,882,288. In that year the total number of births was 123,201 and the birthrate per 1000 of the population was 25.23. The deaths of children under 1 year of age numbered 11,130, giving a death-rate for these children of 90.3 per 1000 births. This figure excludes, of course, stillbirths and all ante-natal deaths. It is 1.7 lower than the rate for 1920, which was the lowest infant mortality rate for Scotland till then recorded.

The corresponding rates for the last 10 years are set forth in the following table compiled from figures supplied by the RegistrarGeneral for Scotland.

INFANT MORTALITY STATISTICS.

We have compiled from returns furnished by medical officers of health certain statistics as to infant mortality, the figures being applicable to the year ended 31st December, 1920. Details will be found in Appendix XII. The death-rates per thousand births are also given for certain age periods under one year.

The total number of deaths under one year, as shown in the returns, was 12,529, and the number of births was 136,546, giving a death-rate of 91-8 per thousand births. The causes of death were measles, 267; whooping cough, 338; diphtheria and croup, 64; tubercular diseases, 273; meningitis (non-tubercular), 258; convulsions, 475; pneumonia (all forms), 1644; bronchitis, 1002; diarrhoea and other digestive diseases, 1525; congenital malformations, premature birth, and atrophy, debility and marasmus, 5168; other diseases, 1515. The death-rates at different ages per thousand births were as follows:

Under 1 week, 23.5; 1 week and under 4 weeks, 147; 4 weeks and under 3 months, 183; 3 months and under 6 months, 153; 6 months and under 1 year, 19.9.

We have arranged that for 1922 and subsequent years the corresponding figures will be compiled and published by the RegistrarGeneral for Scotland, and will therefore agree exactly with those shown in the preceding tabular statement.

RESTRICTION OF PUBLIC EXPENDITURE.

The economic situation has governed the further development of maternity service and child welfare schemes during 1921, and very few new commitments have been entered into. Restriction is doubly difficult in a service such as this that has nowhere reached its full development; and the complete stoppage of all new activities is bound to operate inequitably where the needs of areas vary so largely and where the schemes of authorities are at such widely differing stages of development. It was therefore with considerable regret that approval has been withheld from many proposals that in normal circumstances would have been welcomed.

The effect of restriction however, will be much more evident in future years than in 1921, as a number of important projects that have been developing for some time have only reached fruition in the year under review. Reference is made on page 51 to the steadily increasing correlation of voluntary and statutory nursing services in suitable areas under schemes of maternity service and child welfare, school health administration and tuberculosis, and to the various areas in which comprehensive arrangements of this kind are in force. Much of this provision has become effective during the past year, and that year has also seen the opening of a number of important residential institutions.

NEW INSTITUTIONS.

Seafield House, Ayr.-Maternity and Sick Children's Hospital.

This hospital serves the County of Ayr and the burghs therein. with the exception of the burghs of Ayr, Irvine and Kilmarnock. It provides facilities for the treatment of normal and abnormal confinements and for the non-infectious diseases and ailments of children.

Accommodation is meantime available for 10 adult cases and 34 children.

Barshaw House, Paisley.-Maternity and Sick Children's Hospital.

This hospital serves the Burgh of Paisley. It provides facilities for the treatment of normal and abnormal confinements. Minor operative treatment for children will also be provided and cots for cases of malnutrition will be available. Accommodation is 18 beds and 18 cots.

Bellshill Hospital, Lanarkshire.--Maternity Home and Sick
Children's Hospital.

This institution serves the Middle Ward District of Lanark, but cases may also be received from the Lower and Upper Ward Districts. It provides facilities for the treatment of normal and abnormal confinements and for cases of malnutrition and kindred conditions. The temporary use of Blantyre Hospital building as an annexe to the hospital was approved for the treatment of children. Accommodation is now 40 beds and 10 cots.

Cowcaddens Day Nursery.-Stewart Street, Glasgow.

This day nursery has been erected to replace day nursery premises which were unsuitable for the purpose. It provides facilities for the day-care and recreation of 30 children under 3 years of age.

PROVISION OF FOOD AND MILK.

All schemes of maternity service and child welfare provide that the local authority may on the certificate of their medical officer supply food (including milk) to expectant mothers, nursing mothers, and children under 5 years of age, where it is necessary for the full maintenance of health. In necessitous cases the cost of this provision may be borne wholly or partly by the local authority, according to the means of the recipient. Prior to 1921 there had been no widespread need for the exercise of these powers, and free nourishment was supplied only in a relatively small number of isolated.

cases.

The stoppage in the coal-mining industry in the spring of 1921 was, however, responsible for great destitution in the areas affected, and the local authorities of these areas found themselves faced with the necessity of exercising their powers on a scale that had never been contemplated. Emergency arrangements for supplying food to mothers and children were rapidly made, with our full concurrence, and with almost unqualified success. In carrying out these arrangements considerable assistance was given by voluntary helpers, and the administrative cost was therefore satisfactorily low. We are satisfied, moreover, that in spite of the hastily improvised machinery for distribution neither abuse nor mismanagement occurred to any material extent.

The primary effect of these arrangements was that during the period of stress the health of mothers and young children, so far as the facts could be ascertained in the course of ordinary administration, remained unimpaired. All the reports that we have received are unanimous on this point.

While the settlement of the coal-mining dispute and the consequent return to work eased the need for the provision of nourishment to mothers and young children in coal-mining areas, the spread of unemployment in almost every trade and the locally difficult situation arising therefrom forced the local authorities in many industrial districts to provide additional nourishment in a quite unprecedented number of cases. We refer elsewhere to the steps taken by the various public authorities to relieve distress arising from unemployment, and it is unnecessary to refer again here to the delimitation of function between the several authorities or to the measures adopted to avoid overlapping.

The cost of the provision of nourishment made under schemes of maternity service and child welfare has necessarily been high, but steps have been taken to secure all possible reductions consistent with efficiency. In view of varying local conditions, it has been impossible, of course, to secure absolute uniformity in the methods and scales adopted. Detailed local investigations have, however, been made into the supply of meals by the principal local authorities. and all authorities exercising these powers have been asked to review their arrangements and submit them for approval.

Our circular of 31st August, 1921 (Appendix III.) informed local authorities of the lines that should generally be followed in making their arrangements, and imposed certain restrictions, both as to the persons to be supplied and the quantities of milk to be provided.

While it is clear that these arrangements have been of very great value as an emergency measure in a period of special stress, it is equally clear that the very magnitude of the provision made has created the impression that the maternity service and child welfare scheme is mainly a relieving agency and has thus obscured its primary purpose, namely, the prevention and treatment of illness and the instruction of mothers. The whole general principle has been endangered by a demand for food and milk primarily due to exceptional unemployment and distress, and in our view it is essential, if the primary objects are to be achieved, that the arrangements for emergency supplies of food and milk on a large scale must be regarded simply as measures for relief of distress, and that they shall be withdrawn from association with maternity service and child welfare schemes.

OPHTHALMIA NEONATORUM.

We have been much concerned at the continued prevalence of this preventable disease, and, with a view to securing effective preventive treatment, we issued a circular on 16th July, 1921 (Appendix IV.) The circular recommends the instillation of a solution of silver nitrate into the eyes of the newly born by the medical practitioner or midwife attending the confinement, and calls upon medical officers of health to report to us every future case of ophthalmia neonatorum in which they find appreciable loss of vision.

COMBINATION ORDERS.

Under the powers conferred by Section 3 (1) (a) of the Notification of Births (Extension) Act, 1915, an order was issued combining,

for the purposes of a scheme of maternity service and child welfare the following areas, viz., the five Districts of the County of Perth and the Burghs of Aberfeldy, Abernethy, Auchterarder, Callander, Coupar Angus and Doune.

SCHEMES SANCTIONED.

During the period under review schemes were sanctioned under Section 3 (1) (b) of the Act for the areas of the three Burghs of Arbroath, Kirkwall and Lerwick, and for four combined Districts, viz., Aberdeen County Combination (including the eight Districts of the County and the Burghs of Ballater, Ellon, Inverurie, Kintore, Old Meldrum, Rosehearty and Turriff), Eastern District of Haddington Combination (including the Eastern District and the Burghs of Dunbar, East Linton and North Berwick), Perth County Combination (including the five Districts and the Burghs of Aberfeldy, Abernethy, Auchterarder, Callander, Coupar Angus and Doune), Stirling County Combination (including the three Districts and the Burghs of Denny and Dunipace and Bridge of Allan). An extended scheme of arrangements for the City of Glasgow was also sanctioned.

The above areas, exclusive of Glasgow, embrace a population of 335,691 or 6.8 per cent. of the population of Scotland, and with the schemes previously sanctioned arrangements are now in operation in areas containing a population of 4,303,136 or 88.2 per cent. of the total.

GRANT-IN-AID.

In respect of expenditure in 1921-22, the grant-in-aid will be paid to the extent of 90 per cent. on the basis of estimates submitted by local authorities half-yearly in advance, the balance being adjusted after final audit of the relative accounts.

TRAINING AND EXAMINATION OF HEALTH VISITORS.

The office of health visitor is of recent origin, and the employment of health visitors in considerable numbers dates from the Notification of Births (Extension) Act, 1915, which gave a statutory basis to maternity service and child welfare work. Any endeavour to institute organised courses of training for health visitors during the early stages of this work would have involved the formation of pre-conceived ideas as to their sphere of usefulness, and would thus have limited the free development of the service. The duties required are now, however, more clearly defined, and experience has shown the need for a specially designed course of training. It is clear that the training hitherto available for health visitors tended to lay too much stress on the nursing aspect of health visiting and too little on the preventive aspects. We have, therefore, had under consideration during the year the prescribing of conditions for the training and examination of health visitors.

We requested two of our Consultative Councils, No. 1 (Medical and Allied Services) and No. 3 (Local Health Administration), to report on this question, and in formulating a scheme we have had before us the reports of these Councils, and have also been in

D