Some General Conclusions.

From this analysis certain conclusions are readily drawn.

(1) The infantile mortality of Scotland is falling, and the rate for 1923 (78.9 per 1000) is the lowest yet recorded. But the fall can be accelerated, and it is confidently expected that the measures now being steadily elaborated and developed under the child welfare schemes will help materially in the acceleration.

(2) Certain causes. of infantile death can be more directly prevented than others. For instance, the prevention of diarrhoea is largely a matter of intelligent care. The reduction of deaths from measles and whooping-cough may be secured by better management. It is to be admitted that no measures as yet practicable prevent the epidemics of those diseases, but equally it is admitted that no diseases answer more readily to careful and informed nursing in uncrowded and hygienic conditions. The schemes now possible with the assistance of the grant-in-aid mentioned elsewhere ought to effect some reduction in the deaths from those two very fatal diseases, and from the vast crops of pneumonia and bronchitis that always accompany or follow them. How far it is possible to prevent primary bronchitis and primary pneumonias in infants we have no data for determining, but it is not unreasonable to expect some reduction of respiratory deaths from improvement of housing and the increasing belief in the stimulating and tonic value of the open-air life. Overcrowding in badly lit rooms means greater moisture of the domestic atmosphere and greater sloppiness of the mucous surfaces. Experience at the "toddlers' playground" shows that "running noses" and similar signs of respiratory catarrh tend to disappear rapidly under the influences of the cool air and of the light. How to secure satisfactory open-air life for city infants is itself an immense problem, but the child welfare schemes are showing the way at least to a partial solution.

(3) There remain the most widely fatal causes of all, namely, premature birth and congenital debility. The many special conditions symbolised by these names are being more and more subjected to scientific analysis. Broadly, prematurity and congenital debility depend on the care of the mother through the whole period preceding the birth of the child. This is at once the most difficult and perhaps the most important section of preventive work. It is growing in volume; it is exciting more interest both from the scientific and from the practical side, and there can be no doubt that pre-natal care will soon be valued as highly as post-natal care. It is certain that the largest problem in the prevention of infant deaths centres round. the care and treatment of the expectant mother.

DEVELOPMENT OF SCHEMES.

Our policy during the year, owing to the national financial position, has been to discourage local authorities from entering into new commitments for extended maternity and child welfare services; and, with the exception of two centres in Glasgow, there have been no new developments. We have regretfully had to refuse sanction. to many proposals which involved new expenditure ranging from a few pounds a year to very large sums.

In June the Carnegie Model Centre and the Local Authority's Maternity Home were opened at Motherwell and Wishaw, and in connection with these two institutions there was inaugurated a very complete scheme of medical and social services which will be of first importance in securing improved health conditions in this populous. industrial area.

We have continued our endeavours to secure co-ordinating arrangements between voluntary nursing associations and local authorities On the occurrence of any vacancy or of any proposal for reorganisation we have raised the question of a working arrangement between the district nursing association and the local authority's scheme. Extension along these lines, which in many areas would prevent overlapping and make developments and an improved service possible for both general and specialised nursing, has necessarily been limited by the financial position. A number of local authorities, however, have been disinclined to change the basis of their staffing arrangements.

PREVENTION AND TREATMENT OF MEASLES DURING EPIDEMIC

PERIODS.

The accompanying chart indicates the number of deaths from measles occurring in Scotland in each of the years from 1911 to 1922 in four age groups-under 6 months, over 6 and under 12 months, 1-5 years, and over 5 years.

It will be observed that the fatal cases nearly all occur between the ages of 6 months and 5 years, and experience suggests that if the onset of measles could be postponed until the child reaches the age of 5 years the disease would cease to be an important factor in the death-rates of young persons.

In the last quarter of the year measles, of which Glasgow had not been entirely free at any time for a number of years, again assumed epidemic form in that city and contiguous areas. The weekly number of voluntarily notified cases of the disease rose rapidly to over 900, and the mortality for some weeks averaged over 40. The heavy mortality of the disease in children under school age, the disastrous experience of the epidemic of 1922 in Glasgow and the persistence of the disease in the West of Scotland, led us to consider whether special measures to deal with the whole problem of measles incidence and mortality should not now become a feature of the schemes of maternity service and child welfare administered by local authorities in Scotland.

Glasgow and certain of the other larger local authorities have for some years past availed themselves of their powers to treat measles cases in hospital. Even in some of these areas the accommodation and other facilities for the control and treatment of the disease are probably not fully adequate to deal with epidemics. In other areas there are no institutional or other facilities. We were of opinion. that if any further effective steps were to be taken to reduce the mortality in young children, it was essential that the Government should contribute towards the cost of the special measures which the local authorities would require to undertake. Accordingly, with the consent of the Treasury, we have included a sum of £10,000 in our

estimates for maternity service and child welfare schemes for 1924-5 towards the cost of local authorities' expenditure on this development. £2000 was also made available for the purpose during the current financial year. This additional grant will not be available in aid of the cost of what local authorities are at present doing, but is for the specific purpose of aiding new or extended services.

In order to ascertain the views of authorities as to the lines along which their local efforts may best be directed, we convened a conference of representatives from the larger areas to consider the following points:

(1) increased hospital facilities;

(2) increased health visiting services;

(3) appointment of a special ad hoc staff of infectious diseases visiting nurses;

(4) notification of the disease.

As a result of this conference we have under consideration a circular letter to local authorities intimating details of the further measures we consider necessary for local authorities to adopt. circular will probably be issued early in 1924.

OPHTHALMIA NEONATORUM.

The

In the course of the year we received intimation of the occurrence of five cases of ophthalmia neonatorum in which appreciable loss of vision had resulted. One of our medical officers specially investigated them all. Three of them occurred in a poor law institution in circumstances which led us to appoint a special commissioner to make a formal local enquiry into the whole matter. After full consideration of the evidence and report of the commissioner we severely censured the medical officer of the institution and submitted the papers to the General Medical Council, who took action in the matter.

The Final Report of the Departmental Committee on the Causes and Prevention of Blindness threw into prominence the question of the incidence, prevention and treatment of ophthalmia neonatorum. In order to control the disease more effectively we requested local authorities who had not already done so to make definite arrangements with a suitable hospital whereby any case occurring in their area would receive immediately the necessary skilled treatment. As the efficacy of treatment depends in the highest degree on immediate and almost continuous skilled nursing of the individual case until it responds to the treatment, we require, as a condition of the approval of a hospital for this purpose, the appointment of a sufficient staff trained in the nursing of the disease. This almost inevitably means that other local authorities must use the hospital facilities of the larger centres of population.

With the concurrence of the Scottish Education Department we also impressed upon local authorities and their officers the desirability of securing that every child whose vision is known to be impaired, whether from ophthalmia neonatorum or from any other cause, is brought to the notice of the education authority at the earliest possible moment, so that special education and training may be commenced.