granted under the system of National Health Insurance, it was anticipated that the increase was only temporary, and that 1927 would show a return to normal expenditure. This has not proved to be the case. The expenditure on these benefits was greater in 1927 than in 1926. This increase was surprising and disappointing. It cannot be said that the causes of the progressive increase are fully understood, but the experience of individual societies has been carefully followed, and steps have been taken to improve the scrutiny of claims for benefit, and to bring the disturbing position before certifying insurance practitioners and others concerned with Health Insurance administration.

We wish to place on record our considered view that we attach the greatest importance to correct certification of incapacity for work under the conditions of the National Health Insurance Acts, as our deliberate conviction is that a reliable and correct system of true certification is bound up with and necessary for the financial stability of any scheme of sickness insurance.

Following the line of the last three Annual Reports, we have thought it advisable to give a particular account of several sections of public health administration that are receiving attention from local authorities and their officers at the present time. We direct your attention to the chapters on the Pollution and Purification of Rivers; the Problem of Puerperal Sepsis; the Venereal Diseases, and the Poor Law Medical Service.

In regard to the pollution of rivers, the condition of certain Scottish streams has been, and to a less degree than formerly still is, a matter of concern. The Corporation of Glasgow have spent over two million pounds in purifying the Clyde, and other local authorities on the banks of that river have done their share to render it again worthy of its reputation. The principal statute which deals with the pollution of streams is, however, dated 1876, and measures for purifying both sewage and trade effluents have made a tremendous advance since that date. As local authorities are responsible for preventing the pollution of streams, and as they are also responsible for disposing of sewage from towns and special districts, the difficulties of the situation may be easily realised.

The matter has rarely been one of absolute danger to health,

B

though nuisance has been known to exist, and amenity in many cases has been seriously impaired. As a result of representations on the subject, the Lord President of the Council on 15th February, 1927, received a deputation from the Joint Committee of the British Water Works Association, the Salmon and Trout Association, and other bodies. In his reply the Lord President assured the deputation of the Government's sympathy with their points of view.

Following on this deputation an Advisory Committee on Rivers Pollution Prevention has been appointed for Scotland to consider the position with regard to the pollution of rivers and streams in Scotland, and any legislative, administrative or other measures that appear desirable for reducing such pollution. In view of their activities an exposition of the present outlook, with special reference to the problem of domestic sewage and its disposal, is given in Chapter III.

Reference has been made from time to time in these Reports to the growth of a public opinion favouring further legislation in regard to venereal diseases. Definite legislation has now been brought forward by the Corporation of the City of Edinburgh. Their proposals, which were embodied at first in a draft Provisional Order and thereafter in a private Bill, sought to place upon persons suffering from venereal disease an obligation, under pain of fine, to obtain and continue under medical advice until cured or certified as being unlikely to cause infection. The measure, which was in its application to be limited to Edinburgh alone, was to be further limited to a period of five years. In spite of this we felt ourselves unable to advise you that the possibilities of the present system had been exhausted and that the desired change should be made. The House of Commons, after careful debate, refused the bill a second reading. Other Scottish Local Authorities have under consideration the promotion of legislation designed to secure the same objects as were aimed at by the promoters of the Edinburgh Bill.

The cases of illness referred by Approved Societies and by medical practitioners to the District Medical Officers again provide material for two regional studies, and to these we have pleasure in adding an account of the first year's work of the Dental Officer appointed as a dental referee in connection with work performed under Dental Benefit.

To these notes in regard to matters of outstanding interest we add the following comments on the general health of Scotland during the year.

The population of Scotland in 1927, as estimated by the Registrar-General at the middle of the year, was 4,894,700, and the total death-rate from all causes was 13.5 per thousand persons living. This is an increase on the rate for 1926, which was 13, but is less than the mean of the last five years. The death-rate from all forms of tuberculosis remained at 99 per hundred thousand-the same rate as in 1926. Both the deaths and the death-rate from malignant diseases were higher in 1927 than in any other recorded year.

children under one year of The rate for 1926 was 83.

During 1927 the death-rate of age was 89 per thousand births. The number of children who died under one year of age was 8,577, and, as usual, there was a larger proportion of deaths in winter. Notwithstanding the increased rate compared with 1926, however, the death-rate of infants really continues to decline, as the figure of 89 is less than the mean death-rate of those of the previous five years, and considerably less than the mean of the previous ten years.

The birth-rate for 1927 was 19-8 per thousand persons living, the lowest figure on record.

In regard to the incidence of infectious diseases, the statistics for the whole country have not yet been completed, but the returns from sixteen large towns and two populous counties for 1927 show that there was a slight increase compared with 1926. The heaviest increase was in cases of whooping-cough, and there was an increase in cases of diphtheria and pneumonia. Measles, scarlet fever and tuberculosis showed a fall. In 1927 again, however, the reports of the Registrar-General show that the death-rate from the principal infectious diseases fell; in this case from 0-63 per thousand persons living in 1926 to 0.60 per thousand persons living in 1927.

There were two major outbreaks of infection during the year. One of these was a widespread epidemic of influenza, an illness which is sometimes of brief duration, which produces different symptoms in different individuals, and which is not one of the notifiable diseases. This epidemic had already traversed Western Europe, and became fairly widespread in Scotland in January,

February and March. On the whole it was not so severe nor so fatal as other epidemics in recent years have been, but as influenza may be associated with pneumonia, and may lead to other forms of ill-health, it has a grave influence on health and on mortality. The Health Section of the League of Nations is engaged on an enquiry into the course, extent and nature of the outbreak, and full information in regard to Scotland is being forwarded to Geneva. Both influenza and pneumonia, particularly the latter, demand the closest attention from those responsible for public health in this country.

The other outbreak was one of smallpox, involving 155 cases, and was confined to Dundee and Leven. Fortunately the disease was of a mild type, and in this respect it resembled the type found in recent years in England. For many years Scotland has been fairly free from smallpox, and the limitation of this outbreak to the locality where it arose encourages the hope that if it is again imported into this country the same energetic measures will succeed in stamping it out before it spreads.

It is interesting to observe the total number of deaths from various causes, as recorded in the Registrar-General's report. During the year the principal causes of death were as follows:from heart disease 7,900; from malignant disease 6,918; from apoplexy 6,053; from all forms of pneumonia 5,894; from bronchitis 3,914; from diseases of early infancy 3,736; from pulmonary tuberculosis 3,466; from influenza 2,026; from nephritis 1,870; from diarrhoea and enteritis (under two years of age) 698; and from measles 660.

CHAPTER I.

HOUSING.

1. Houses completed in 1927.-The year 1927 marks a record year in the history of house production in Scotland. In the Report for 1924 it was indicated that the completion of 20,000 houses per annum was necessary during each of fifteen years if at the end of that time Scotland was to be regarded as an adequately housed country. As, during that year, only 4,384 houses were completed under State-assisted schemes, the attainment of an output of 20,000 houses seemed far off. In three years, however, this output has been achieved, and justifies the statement in the Report for 1926 that the housing situation in Scotland could be regarded with more confidence than at any time since the inception of State-assisted schemes in 1919.

During 1927, 19,048 houses were completed by local authorities and private enterprise under the various schemes of State assistance, 1,110 were completed under the steel houses scheme which is being carried out by the Second Scottish National Housing Company (Housing Trust), Limited, on behalf of the Government, and 1,502 houses of a working class type were erected by private enterprise without any form of assistance, making a total of completed houses for the year of 21,660, as against the corresponding figure of 14,930 houses for 1926. The 1927 figure is probably the largest number of houses ever built in Scotland in any one year, and represents the provision of houses for a population equivalent to that of Greenock or Paisley.

As 10,000 houses have been estimated as required annually in Scotland to meet normal requirements, it follows that, in 1927, 11,660 houses have been made available towards the reduction of the housing shortage to which reference was made in paragraph 8 of the Report for 1926.

2. Prospects for 1928.-There seems little reason why this rate of output should not be maintained in the year 1928. At the beginning of that year there were 17,547 houses under construction by local authorities and private enterprise with State assistance, 314 houses were under construction under the steel houses scheme of the Government, tenders had been definitely approved for 7,325 houses to be erected by local authorities though the work had not been begun at 31st December, 1927, while local authorities had approved for erection by private enterprise with assistance 1,537 houses not begun. There were therefore 26,723 houses under construction or definitely arranged for, as compared with the corresponding figure of 28,450 at the beginning of 1927. Despite this slight decrease there are good grounds for the view that the year 1928