by the number of small institutions that were built before the introduction of motor ambulances. It is not possible in very small hospitals to secure the same degree of efficiency in equipment, staffing and segregation of separate infections as is the rule in larger institutions. Whenever opportunity occurs we continue to bring this consideration before local authorities but without much success. Public opinion has grown accustomed to the convenience of the local hospital and continues to demand in the interest of the convenience of visitors local facilities, and perhaps without full regard for the welfare of the patient and the ultimate gain in efficiency and economy of the larger hospital serving a wider area.

INFECTIOUS DISEASE (NOTIFICATION) ACT.

In terms of Section 7 of the Infectious Disease (Notification) Act, 1889, we approved the following permanent extensions of the Act by local authorities, viz. :-

Disease.

Stirling County-Eastern District ... Anthrax in Man.

Local Authority.

Aberdeen Burgh

...

Johnstone Burgh

...

Acute Encephalitis
Lethargica.
Cerebro-Spinal Fever.

A list showing the areas in which at 31st December, 1914, the Infectious Disease (Notification) Act had been extended permanently to include infectious diseases other than those mentioned in Section 6 of the Act is printed in Appendix B., No. 16, of the Local Government Board for Scotland's Annual Report for 1914. The names of local authorities that have since extended the Act are given in the Annual Reports of the Local Government Board for Scotland and of the Scottish Board of Health for subsequent years.

INFECTIOUS DISEASE NOTIFICATIONS.

Statistics as to the number of cases of infectious disease notified to local authorities during the year ended 31st December, 1922, have been compiled, and a summary, showing, according to age-periods, the number of cases of each disease notified in counties (landward) and burghs, will be found in Appendix II.

Of the diseases compulsorily notifiable throughout Scotland, those which are specified in the Infectious Disease (Notification) Act, 1889, are shown under head A, and those which were made compulsorily notifiable by Regulations made by us under Section 78 of the Public Health (Scotland) Act, 1897, are shown under head B. Diseases to which the provisions of the Infectious Disease (Notification) Act have been extended voluntarily by certain local authorities are shown under head C.

The following table shows in respect of each disease the total number of cases notified in counties (landward) and in burghs

respectively, and the number and percentage of such treated in hospital:

Counties. Burghs. Counties. Burghs. Counties. Burghs.

Since the beginning of February we have obtained from the medical officers of health of the sixteen large towns with a population

of over 30,000 (for which the Registrar-General for Scotland publishes weekly statistics of births, marriages, and deaths), and the populous industrial counties of Fife and Lanark, weekly returns of cases of the principal infectious diseases notified or becoming known to them, viz., diseases notified under the Infectious Disease (Notification) Act, 1889, and our Orders, diseases to which the Act has been extended in the areas, and diseases otherwise becoming known to the medical officer of health. The returns are summarised and an abstract furnished each week to the medical officers of health who supply returns, and also to the Ministry of Health and to the Navy, Army and Air Force Medical Services. Copies of the abstracts may be obtained by any other medical officers who desire them.

PORT SANITARY ADMINISTRATION.

During the year we approved schemes of port sanitary administration and of medical inspection of aliens for the Port of Glasgow, and for purposes of grant approved details of expenditure (salaries of officials, provision of hospital accommodation, etc.) under these and other schemes. Schemes of port sanitary administration have now been approved for the ports of Glasgow, Edinburgh, Dundee, Aberdeen, Ayr and Troon, and schemes of medical inspection of aliens for Glasgow and Edinburgh. No questions of importance arose under those schemes in the course of the year.

DISINFECTION OF SHIPS.

Under the Quarantine Regulations in force in the United States of America all vessels engaged in trade with foreign ports are required to be fumigated not less than once every six months for the purpose of destroying rats. It has been found possible for the port medical officers to render material assistance to Scottish shipowners in the matter, and the courtesy of the United States Public Health Service has enabled compliance with the Regulations to be effected at a minimum of inconvenience and expense to shipowners.

Maternity and Child Welfare.

CHILDREN UNDER 5 YEARS-NUMBERS AND MORTALITY.

The estimated population of Scotland in 1923 was 4,901,100* In that year the total number of births was 111,902 and the birthrate per 1000 of the population was 22.8. The deaths of children. under 1 year of age numbered 8825, giving a death-rate for these children of 78.9 per 1000 births. This figure excludes, of course, still-births and all ante-natal deaths. It is 22.5 less than the rate for 1922 and is the lowest on record.

The rates for the last 12 years are set forth in the following table compiled from figures supplied by the Registrar-General for Scotland.

In our Report for last year figures were shown (Appendix V.) giving the details of the mortality of children under 1 year of age in the various age-groups. Corresponding figures for the year 1922 are published in the Annual Report of the Registrar-General for Scotland, 1922 (Table 48). The figures for subsequent years will also be compiled and published by him.

INFANT MORTALITY IN SCOTLAND.

Infant mortality in England has now fallen considerably below the infant mortality of Scotland, and the rate of decrease in England is greater than the rate of decrease in Scotland. We have devoted attention to an examination of outstanding points in the incidence and causes of infantile mortality in Scotland as compared with England.

"Conventional" and "Corrected" Death-Rates.

"Infant mortality" here means the ratio of the deaths of children under 1 year of age to the number of births occurring in the year in which those children die. This is the conventional method of reckoning infantile mortality. Unfortunately it is not free from fallacy and cannot always be relied upon as an index for comparative purposes. The reason is obvious. When the birth-rate varies slowly from year to year, the death-rate under 1 per 1000 births is convenient and reliable. But, where the birth-rate varies rapidly, as it did in the years 1915-16 and again in the years 1919-20, the deathrate per 1000 births varies considerably. To meet this difficulty the English Registrar-General has made elaborate corrections, with the result that his "corrected" infantile death-rate and the "conventional" infantile death-rate differ a good deal, sometimes as much as three or four units per 1000. The correction has not been made in the Scottish Registrar-General's Reports, and it is, therefore, impossible to compare the Scottish and English figures except, as formerly, on the "conventional" basis, namely, the crude death-rate of children under 1 per 1000 births of the year in which the children

die. (The English "corrected" rate is obtained by relating the deaths of the children to the births of the quarter of the year in which they were born. It is easy to see that if, as in 1915 and in 1919, the birth-rate in those quarters dropped suddenly, and if the deaths were calculated on the increased birth-rate of the following year, the result would be a false lowering of the death-rate. The converse would be true if the birth-rate suddenly rose.) As the result of the rapid variations in the birth-rate in the years 1915, 1917, 1919 and 1920, the comparison with English figures must be taken as only approximate. Without an elaborate application to the Scottish data of the method used by the English Registrar-General, a more exact comparison is not possible.

For the method of correction to eliminate the distortion of the birth-rate as a cause of variation in the infantile death-rate, see English Registrar-General's Report, 1920, page xxxi. The English Registrar-General writes:-" As was to be expected, the two rates (that is the crude rate and the standardised rate) are closely approximate during the four years 1911-14 before war disturbance of the birthrate had set in, thus proving that in ordinary times the crude rate is quite sufficient. In 1915 the first sharp fall in the birth-rate occurred, and the crude infant mortality was exaggerated in consequence. A still greater fall in the birth-rate occurred in 1917 and was accompanied by correspondingly greater exaggeration of infant mortality. Towards the close of 1919 a sharp rise occurred in the birth-rate, which was continued in 1920, infant mortality being consequently much understated for both years by the crude figures. But a far more striking illustration of the unreliability of crude infant mortality rates during a period of rapidly fluctuating birthrates is provided by comparison of the conventional rates for the four quarters of 1920 with those obtained by relating the deaths to the corresponding births." In the first quarter of 1920 the conventional figure gave 88 per 1000, while the crude rate gave 109 per 1000; in the second quarter, 81 per 1000 as against 87 per 1000; in the third quarter, 64 as against 63, and in the fourth quarter, 85 as against 79; for the whole year 80 as against 85. These variations show that the conventional rate must be interpreted with caution.

General Comparison of England and Scotland.

Broadly it can be said that the trend of infant mortality both in Scotland and in England has been, with many variations, downward. In England the infant mortality rate in the quinquennium 1896-1900 still stood at 156. In the quinquennium 1901-05 it was 138. By the quinquennium 1911-15 it had fallen to 110 and in the quinquennium 1916-20 to 90. In 1921 the rate was 83. In 1922 it was 77. This fall is extremely rapid and relatively sudden. Part of the decrease has been due to the decline in infantile diarrhœa ; but there has been a general reduction in the deaths due to other causes. Curiously, as pointed out by the English Registrar-General, the most marked decline in infant mortality has occurred in the third and fourth quarters of the year. He writes:-"Comparison of the rates shown in Table 21 for 1912 and for 1920 shows a decline of non-diarrhoeal mortality in the latter year of 54 per cent. in the first quarter, 1-2 in the second, 22-3 in the third and 240 in the fourth.