Stornoway, 11 October 1912 - Dr Donald Murray

10372. (Chairman) You are an MB, CM (Glasgow) and DPH (Aberdeen)?

10373. You are the Medical Officer of Health for the Lewis District of the County of Ross and Cromarty; you are the Medical Officer of Health for the Burgh of Stornoway, and you are also Medical Officer to the Hospital for Infectious Diseases, Mossend, Stornoway?

10374. You are also Certifying Factory Surgeon for Lewis, and School Medical Officer of B. District of Ross and Cromarty, which includes Lewis and five parishes on the western seaboard of the country?

10375. You have been engaged as a Medical Officer of Health for about six years and as School Medical Officer for amost two years?

10376 You devote your whole time to public service, or have you any private practice besides?
—No, not now. Since I took up School Medical Inspection I gave up private practice.

10377. You know the social condition of the people intimately?

10378. You own a motor—car?
—No, I hire it.

10379. It costs you 1s. 9d. per mile?
—Yes, a double mile.

10380. If you owned the car you could run it much more cheaply?
—It all dpeends on the amount of work. I believe I could.

10381. Can a car get to all the various townships, or are there some that are not approachable by car?
—There are some that are unapproachable by car.

10382. What have you to say about the insecurity or security of tenure of parish appointments?
—As far as my own experience is concerned, and the experience of the medical officers I know, I don't think there has been very much difficulty about that with Parish Councils.

10383. Were you a parish medical officer before you got this appointment?
—Yes, in Sutherlandshire and Stornoway.

10384. You have had no trouble with your Parish Councils?

10385. But you have heard of other cases?

10386. You think medical officers should have the right to appeal to the Local Government Board?

10387. Would you do anything to prevent an unreasonable doctor who was unpopular being permanently fixed as the only medical officer in a parish?
—I am quite alive to that point. I do not think that a doctor who is unacceptable to the people should be permanently foisted on the community — I mean, to a certain extent, the people should have a free choice and the doctor should have a free choice.

10388. You have not thought out any scheme whereby that could be carried out?
—If the council were unanimous it would be unreasonable to say that there was not reasonable grounds fordismissing the doctor?
—Unless the grounds of dismissal were of such nature that they would appeal to everybody, then probably the Parish Council should not be able to dismiss him without what you might call a general election.

10389. Have you thought of having a larger area for the control of the doctors?

10389A. Would that meet the difficulty to some extent?
—Yes to some extent, I believe it would. It would meet among other difficiulties the difficulties of rearrangement of areas.

10390. What about vaccinations? Can you tell us f since the COnscientious Objectors' Act came into force there have been fewer vaccinations?
—Before I left practice I only met one modified conscientious objector, and since then I have just heard of one or two individuals in the town; but my neighbours in other parishes, in the parish of Barvas for instance, find that the conscientious objectors are spreading to a large extent.

10391. Is it your experience that the objection is only conscientious on the surface?
—I do not believe it is conscientious at all. It is simply to save trouble.

10392. Can you tell if it is resulting in very few vaccinations taking place at all in the district?
—The Island is very well vaccinated, but I was speaking to another medical officer who told me that in his district quite a number are refusing.

10393 We have had evidence in Scotland that quite a number of doctors find there are practically no vaccinations now at all?

10394. There is no club here?
—There is only one lodge of Oddfellows in the town of Stornoway.

10395. How does it work?
—All right.

10396. Are there many members?
—I should imagine there were 300 in it when I was joint officer.

10397. What was the fee?

10398. And that included medicines?

10399. Had you any frivolous calls?
—I cannot say there was much of that.

10400. Was there very much serious illness among theM?
—No, I do not think so.

10401. How do you think the present difficulty with regard to medical attendance in the Highlands might be improved. Do you think it might be improved by estalishing a modified system of club payments; that is to say, that the families who do not require the doctor very often should still pay a certain sum each year, which would help to defray the cost to the people who are more or less invalids?
—I do not think it could work without external help.

10402. Supposing it was made universal in the island of Lewis, that each family should subscribe a sum per family, what do you think is the most that we should ask the least able to bear the burden of medical attendance to pay?
—I have been trying hard to fix a sum like that for my own satisfaction. It is very difficult to say. I think in Harris they pay 5s, if I am not mistaken, and it works fairly well.

10403. Of course there are certain people who could not pay even 5s?
—There are always some of that sort.

10,404. These should be exempted the same as from the rates ?

10,405. You think the great majority of them could pay 5s. a year per family ?

10,406. I suppose it is your view that the insurance against sickness of the head of the community is not an important thing?
—Yes, that is so.

10,407. But the children and the wife need a good level of medical attendance ?

10,408. Outside the burgh of Stornoway, crofting, fishing and ghillying are the main occapations of people?
—There is very little ghillying.

10,409. Do,you think there are many people in the island of Lewis who are in great need of medical attendance wh don’t get it ?
—Yes, but I should not put it plainly. They get it, but they have difficulty in getting it.

10,410. Is it your view that in a.great many cases a doctor is called in at a later period ?

10,411. Do you think the reason of that is that they are afraid to run up a bill

10,412. So that by the payment that you support through a club system, that difficulty

110,413. Supposing some such system as we have advocated were adopted, do you think it would be necessary to have a small fee to prevent frivolous calls upon the doctor?
—Yes. From the point of view of the doctor, I think it would be necessary at a distance. I would have a fee for the first visit to a particular illness anyhhow, then a doctor could see for himself whether it was a frivolous call or not, and he could either modify his fee or have nothing at all for that particular illness, according to a definite

10,414. What fee do you suggest?
—I think they would be quite willing to pay 1s. 6d. to 2s. for the first visit.

10,415. Even with 5s. a family, you would have a fee like that for the first visit. That would not be enought to give the doctor a remuneration ?
—No, it would not; the fees would be paid in to a central fund.

10,416. It would need to be augmented in some other way?
— Yes.

10,417. It is at present augmented. by the poor rate to some extent ?

10,418. Your experience of the doctors is that many practically receive a remuneration, having reported the work they do, that they might reasonably expect. I think that is true of the island parishes particularly.

10,419. Is there much tuberculous disease, either pulmonary or non—pulmonary, in your district? The average number of deaths per annum from pulmonary tuberculosis in Lewis is 51. The average death—rate from these causes is 1.8 per 1000 while the average death—rate from same cause for England and Wales is 1.14 per 1000. The death rate from all forms of tuberculosis in Lewis is 1.9 per 1000, and in England and Wales it is 1.64 per 1000. Since compulsory notification of pulmonary tuberculosis came into force, since 1st August the number of notifications received up to 23rd August was 32. These figures include the burgh of Stornoway.

10,420. (Dr Mackenzie.) What number of years are you taking for that average ?
—The last eight years.

10,421. (Chairman) Can you say it is increasing or decreasing ?
——I may say it is increasing. The number from last year was decidedly lower, but from what I can see from statistics the number for this coming year will more than compensate for it.

10,422. We have had some evidence from various doctors in various parts of the Mainland.They say that a good deal of it is imported from the South, that the natives go South and come back with consumption and die. Do you find much of that here ?
—There has been a good deal of it in recent years. In fact, my predecessor, the late Dr MacRae, used to tell me when he was a boy, there was practically no tuberculosis in Lewis. It was imported, and when it came in it found the circumstances favourable to its spread. At present we find people returning from the South with consumption but that they got the infection before they left or in the island is hard to say. They come home from Glasgow or Edinburgh and other cities in the South to die.

10,423. You have not had any of your own patients in your own practice, who have come back in this condition ?
—Yes, lots of them.

10,424. Could you tell us what they blamed for contracting it in the South?
—The usual story was that they took a cold and a cough. They usually talked about that it was a cough.

10,425. So that you don’t know whether it was the condition of life in the South or what it was that was the cause of it ?

10.426. (Dr Mackenzie) In any case, you don’t consider that the conditions that these girls would be living under in the South would be very much worse than any of the conditions in the island of Lewis ?
—No ; considerably better.

10.427. So that if the conditions of living had to do with it, the probability is that many of them would have contracted it here before they went, or, at any rate, it is quite possible that they would contract it here as in the towns in the South?

10.428. The conditions of life are perhaps on the whole better in the South than they are here ?
—They are better in the South. Of course these are a minority of the consumptive cases we have in the island.

10.429. You are quite satisfied that a large quantity of tuberculosis, regardless of this particular item, is endemic in Lewis?
—Yes, undoubtedly.

10.430 (Chairman). We had evidence, I think, from Shetland from a doctor, and he blamed the accommodation in some of the fishing boats ?
—I often thought of that too, as a contributing cause, but I think we have as many girls contracting consumption in Lewis as there are of men.

10.431. With regard to nurses, in the whole island of Lewis, you think they are insufficient at present ?
—They are insufficient, but the ones we have are pretty good. I would like to see the nursing system improved.

10.432. We had evidence in Edinburgh of some nurses supplied by the Free Church Association. Do you know them?
—Yes. They contribute to their support; they don't supply them. It was the District Committee really that started them. They get these contributions from the Ladies Association. They have nine, I think, now—two in each parish and three in Uig.

10.433. The Ladies Association does not control them in any way?
—They lay down certain conditions under which they contribute half the salary. There is the local Committee and they are to some extent under the locallocal Committee

10,434. What is the local Committee?
—A voluntary committee.

10,435 Are these nurses at the same time missionaries?
—No. That is a different organisation in Edinburgh. They are not trained nurses they give; I think that is a purely United Free Church thing—managed by Mrs Whyte, Edinburgh.

10,436. That is not Miss M'Phail’s. They used to supply teachers and afterwards they turned their attention to nurses?

10,437. Miss M‘Phail’s nurses are trained to some extent. Some of them, I think, were trained in the Govan Hospital?

10,438. There are nine of Miss M‘Phail’s. What other ones have you?
—The only other one we have is a nurse to nurse cases of infectious diseases at their own homes.

10,439. Is she paid by the Public Health Authority ?

10,440. Have you any fully trained nurses, Jubilee nurses or Queen's nurses?
—There is usually one in the town of Stornoway here; she is in connection with the hospital, where she acts as matron as well as district nurse.

10,441. What about the hospital ; is it a voluntary institution?

10,442. How many beds are in it ?

10,443. Is there more than one nurse there ?
—Yes, two, and a probationer. There is a matron and a staff nurse there, as a rule.

10,444. How many more nurses do you think you could have in Lewis?
—I should like in the parish of Stornoway to see one in North Tolsta and at Aird. There are 4000 people on the Eye Peninsula, and there is no doctor there. All the doctors live in the town.

10.445. Is it convenient for access? Is there a road all the way?
—Yes. There is a nurse five miles away.

10,446. Is this one of your most congested districts ?
—Yes, but it is one of the best off districts. There is a nurse at Back, and she is supposed to do Tolsta.

10,447. What is the population of Tolsta ?

10,448. Tolsta is fifteen miles from the doctor, and there is no nurse?
—That is so.

10,449. There is another district, you say, would require a nurse. What is it?
—Balallan and Brenish districts.

10,450. What is the population of Luirbost?

10,451. The nurse is fully occupied with that population?

10,452. What is the population of the Balallan district?

10,453 You think there should be another nurse for that district?

10,454. Are all these supplied with a doctor at Stornoway?
—No, from the doctor at Lochs.

10,455. How far is that from Balallan ?
—About five miles.

10,456. There is a nurse at Crowlista in the parish of Uig, but you think there should be another there ?

10,457. Where would you place her ?
—Within easy reach of Brenish.

10,458. Could you tell us the population there ?

10,459. Should there be a nurse for that population of 241 ?
—I admit it is a small population, but I think of the distances from the doctor. That district is about thirty miles from the doctor. A rearrangement of the nurses’ residences would be required.

10,460. A special nurse is sent for infectious cases ?

10,461. Are they treated in their own homes ?
—She is only employed for them at their own homes. In the burgh we usually take these cases to the hospital, but we don’t often take them to the hospital from these outlying districts because of the difficulty of transit.

10,462. How are you off for telegraphs and telephones?
—The telegraph system has improved. I don’t think in many parts they have got to go very far for a telegraph office At Brenish they have to go about ten or eleven miles to a telegraph office.

10,463. The telegraph system is fairly well developed ?

10,464. Have you any telephone?
—None except in connection with the telegraphs. In the burgh we have telephones.

10,465. Can you tell us if a doctor is allowed to speak over one of these telephones ?
—Not under the present conditions.

10,466. Have you ever tried ?
—I have never had occasion to try. I should imagine it is against the regulations.

10,467. It is quite possible that it could be done ?
—I have never thought of that. I don’t see why it should not be done.

10,468. Do these hospital nurses nurse infectious cases—I mean these district nurses ?
—Occasionally they do. That was one of the conditions on which the District Committee paid a portion of their salary.

10,469. Is not that a dangerous thing when they nurse maternity cases ?
—Yes, but as a matter of fact they don’t very often go to infectious cases, and when they do they are debarred from maternity cases.

10,470. Are not maternity cases mostly in charge of nurses, or is the doctor in attendance too ?
—He is in attendance at a fair proportion of them.

10,471. And as for the others, the doctor is never called in unless there is trouble ?

10,472. You have suggested here that the District Committee might be the authority for controlling the doctors, and that they should have an appeal to the Local Government Board?
—Yes, with medical men co—opted to the District Committee.

10,473. What have you to say with regard to the adequacy or inadequacy of medical and nursing provision in the district ?
—It is inadequate in these respects, viz., Notwithstanding the fact that medical fees are smaller in Lewis than in most places, patients at a long distance from the doctor’s residence find it extremely difficult to pay ; therefore the doctor is sent for usually only when the case is extremely grave, thus valuable time is lost.

10,474. Can you tell us What fees are usually charged?
—Roughly, about 1s. a mile.

10,475. (Dr Mackenzie.) Is that 1s. a double mile ?
—1s. a double mile.

10,476. (Chairman.) If you hired it would cost you more than that to hire ?

10,477. That is notoriously too little for the doctor, but in many cases it is too much for the patient to pay ?
—Yes, at least for continued attendance.

10,478. (Dr Mackenzie.) Do they charge an ordinary fee over and above the 1s. a mile ?

10,479. (Chairman.) You say: "Even when the doctor is called to see a serious case (e.g. acute pneumonia), he probably only sees the patient once during the illness unless he happens to be in the district visiting some other patient, therefore the management of the case is not under his immediate supervision." Is it impossible to remove a case of pneumonia to the hospital?
—It is impracticable.

10,480. (Dr Mackenzie.) You don’t consider one visit enough in a case of acute pneumonia ?
—No. It is often the case that that is the only visit they get.

10,480A. How many visits do you think would be enough ?
—In the town the patient would be visited twice a day, and if the case is in the vicinity of the town, once a day. I think a case of acute pneumonia should be seen every second day by a doctor. When there is a trained nurse in attendance it relieves the anxiety of the doctor about his case, but even when there is a nurse there in a case of that sort the doctor should see the patient every second day.

10,481. (Chairman.) You say,
(3) "Many illnesses, so—called ‘minor’ ailments, tumours of various kinds, etc., requiring early detection and attention, are allowed to go on until they become chronic or incurable (e.g. tuberculosis and malignant diseases).
(4) Infectious diseases, unless the symptoms are very alarming, are often allowed to go too far before the doctor is called, and thus others become infected before the diagnosis is made.
(5) The number of uncertified deaths tell their own tale."
Can you tell us something about that?
——The average for the past five years in Lochs, Barvas, and Uig parishes together was 37 per cent., roughly. It has been improving. In 1907, 1908, 1909, the figures were 42 per cent., 40 per cent., and 48 per cent. respectively. In the parish of Stornoway the average was about 16 per cent.

10,482. Why should the average be 16 ?
—We have one village fifteen miles and some ten miles away from the doctor. For the burgh it would be very much smaller; last year it was 12 per cent. The worst averages are in Uig. For 1911 it was 33 per cent. ; Lochs, 22 per cent. ; Barvas, 20 per cent.; and Stornoway (landward), 26 per cent. These are the percentages of uncertified deaths.

10,483. (Dr Mackenzie.) What were the absolute figures that you calculated your percentages on?
—1889 deaths in the four parishes, exclusive of the burgh, in 5 years ; 380 deaths for 1911 ; 40 deaths in the burgh in 1911.

10,484. (Chairman.) You say the worst is 33 per cent., and yet you gave us the average as 37 per cent. ?
—This is for 1911.

10,485. What was the 37 per cent. ?
—It was an average for five years.

10,486. And the average for five years is 37 per cent., and the worst for last year was 33 per cent., so, apparently, they are improving ?
—Yes. I have another figure, the total for 1911—it was 96 uncertified.

10,487. What percentage of the total deaths is that ?
—25 per cent.

10,488. Can you give us the ages ?
—For last year, under one year there were 9 uncertified; from five to fifteen there were 8 uncertified; from fifteen to twenty—five, 1 uncertified ; from twenty—five to forty—five there were 2 uncertified; from forty—five to sixty—five there were 8 uncertified ; and over sixty—five there were 68 uncertified.

10,489. Where did you get your figures from—direct from the Registrar’s figures ?
—Partly. The local doctors get them from the Registrar and send them to me. The average for Stornoway is taken from Public Health records ; but a truer average would be that for the past three years, namely, 24 per cent. for the landward portion of the parish.

10,490. What do you think is the reason for the want of medical attendance in these cases?
—I think the chief reason is the large fee that is necessary for those who intend really to pay. Of course, some of them don’t intend to pay. The distance from the doctor has got them into a condition of mind, apart from the question of fee, that they don’t think it is the right thing to send for the doctor until things are looking very serious.

10,491. (Dr Mackenzie.) Can you give us a figure exactly for all those above sixty—five? Is there any sign that that is a serious reduction ?
—I cannot give you that.

10,492. Could you get that? It would be an indication of whether more attention is being paid to the old people than formerly ?

10,493. (Chairman.) With regard to question 34, you say that patients at a distance should have as cheap medical attendance as those living near the doctor. A maximum fee payable by the patient of, say, 2s. 6d. for the first visit, and a smaller fee or none for subsequent necessary visits during the same illness. Do you wish to say anything further on about a club system?
—Yes, I think I do.

10,494. You also say that any new arrangement should include provision for every member of a family, that the local doctor should have clinical charge of all cases treated locally—infectious and non—infectious; and you also say that visits should be made by the doctor to remote parts of the district on fixed days at reasonable intervals. Is that in force in any of the districts here?

10,495. You say that a fully trained nurse should be available for the furthest away villages, and that she should be properly housed, and that one of the rooms should be available for a consulting room for the doctor. You also say that a bed or two for nursing special cases might be an advantage. That is to say, there should be some cottage hospitals in various places ?
—Yes. Of course, with regard to the expense, it would need to be for very special cases — I mean cases that the nurse could leave, little operations and things of that sort that the doctor might not think of sending to an hospital.

10,496 You also say that with motor travelling the question of additional doctors is, in your opinion, not so urgent as that of cheap medical services. That is to say you believe there are enough of doctors in the island for the population?
—I should not like to say that absolutely.

10,497 (Dr Mackenzie). You mean that there should be an increase of the medical service as well as an increase of the motor appliances, but that motor travelling is more urgent than the other?
—Yes that is so. I believe if the improved medical service is going to do what you intend it to do, to make the service more efficient, it will mean, of course, very much increased work for the doctor. I believe at any rate eventually, an increased staff will be necessary.

10,498. (Chairman). If at present the people who are not getting medical attendance do get, it will mean more work?

10,499. And you think that more doctors will be necessary?
—Yes, later on.

10,500. In regard to motor travelling, would you approve of a scheme whereby every doctor should be able to keep a motor—car?
—Yes, I think it would be a very great advantage. I made a suggestion of that sort to the Local Government Board a few years ago. I looked upon it as the solution of the problem.

10,501. The rates in Lewis are at present in such a condition that no further charge can be laid upon them?
—That is so.

10,502. You say that for the parishes of Barvas, Lochs and Uig there should be a guaranteed minimum salary, and that if additional doctors were appointed the minimum would require to be substantially increased?
—In the Burgh and surroundings of Stornoway you will have a large number of insured people, and assuming that arrangement with the doctors comes into force, that will make a considerable nucleus in the burgh of Stornoway. For that and for other reasons the problem is different to that presented in the other parishes, except with regard to mileage and similar questions. I don't wish to limit the income of doctors.

10,503. When there is more than one doctor it is difficult to deal with it in that way?
—Yes. Of course in larger towns it is not so necessary to have a subsidy for the doctor as it is in the country. Even here a subsidy is absolutely necessary, or else a doctor could not make much out of his practice in the parish of Stornoway.

10,504. Do these three parishes include all except Stornoway?

10,505. You say that there should be a suitable house and surgery at a convenient centre?

10,506. Have they all suitable houses in the district?
—They all have a house, but whether they are satisfied with them or not they will be best able to say.

10,507. You say that you agree as to the rate per visit and for mileage suggested by the local doctors, and the suggested provision for holidays, and you also say that certain fees for "extras", such as confinements, night visits, operations, etc, should be fixed. You say that the patient should be charged an extra fee for messages sent in after 10 a.m. Do you mean p.m.?
—Not in this connection. My experience is that quite a large number of the calls could be sent in before 10 a.m.. I was in practice in England where almost every call was in before 10 o'clock, and from my experience here I quite believe that 90 percent of the calls could be in before 10 a.m., and therefore the doctor could do three times the amount of what he now does.

10,508. (Dr Mackenzie). That applies in the country as well as the towns?

10,509. You would look upon a message for a doctor sent in the night before as sent in before 10 a.m.?

10,510. (Chairman). You would suggest that small hospitals for the care of infectious cases might be placed at convenient centres in Lewis. Does not that lie with your local authority?
—I don't see why, if there is any improvement to be made in the medical service, this should not fall under these improvements. The maximum public health rate of 1s. in the £ has been long exhausted.

10,511. You think an hospital and sanatorium for tuberculous diseases is urgently required, and you also think that definite arrangements should be made for the treatement of defects in school children. You say you believe that a properly organised medical service must eventually be under one authority with medical local responsibility—this service to include "public health", clinical attendance, and several other definite medical activities now organised under separate authorities. There is scope and need for a unified system, and the Highlands and Islands present a good field for a beginning ?
-Probably that is outside your remit.

10,512. (Dr Miller). In regard to the raising of the efficiency of medical services in these parts you quite agree, of course, that the remuneration to the doctors has to be nursed and improved?

10,513. And you also agree that another method of improving the efficiency would be to raise and secure the personal status of the individual practitioners?
— Yes, decidedly. I must say we have an excellent staff at present in the island, and I don't know that you could improve upon them.

10,514. You do agree that, as a matter of fact, on principle you could improve the efficiency of the service by improving the status of the practitioners ?

10,515. And that personal status you could improve, could you not, by scouring such a matter as protection against frivolous dismissal?
—Yes, I must say for the Lewis parishes I really don’t think any of them would be guilty of frivolous dismissal

10,516. As regards yourself, of course, when you held the parochial appointment here you were secured against frivolous dismissal?

10,517. You are secured against anything like dismissal in regard to your Public Health appointment?

10,518. And formerly in regard to the Parish Council appointment?

10,519. You have stated about your being Medical Officer to the Oddfellows in this place at 3s. per head per annum?
-Yes, in recent years, and in the earlier years it was 2s. 6d.

10,520. Of course, these were picked lives, carefully examined?

10,521. So that you would not regard it as a basis for a capitation fee for the general population who are not picked lives?

10,522 There are local doctors who act as your substitute in the outlying districts, or rather are appointed directly by yourself and hold office at your pleasure?

10,523. I think you would admit that that is a system which might be capable of a little improvement ?
—Yes, I am not bound to apppoint him ; it is simply to suit my own convenience. I do the chief administrative public health work myself.

10,524. Is it a matter of pure philanthropy and gratuity that you do that?
—No, I did not finish my sentence. I mean to say that it is for my own convenience that I ask them to become local medical officer of health and do certain work for me when I am absent, and also at the same time they hold themselves bound to attend to any infectious cases that may not be sent to the hospital. But I would prefer that they should be officially recognised as part of the Public Health administration.

10,525. I suppose one may be right in assuming that you find it advantageous to have the local men assisting you?
-Decidedly. I would have the local men assisting me in every department of my work. I am strong in having the local medical men connected with every branch of medical service.

10,526. You have had experience of the kind of conditions under which men live in the fishing-boats here?

10,527. Do you think that their sleeping accommodation is as a rule sufficient ?
—No; I have often thought that it would need looking into.

10,528 Have you as a Public Health authority any jurisdiction as regards the inspection of the boats ?
—Yes, I believe I would have if they are at the pier.

10,529. Do you think it is a matter that might be drawn attention to?

10,530 You have gone very fully into the question of nursing and obviously the nursing service for 30,000 of a population is very defective as it stands at present?

10,531. (Dr M‘ Vail.) How long were you in practice?
-For about fourteen years, and I was five years in Sutherlandshire.

10,532. You are out of practice now altogether ?

10,533. Did you keep your books pretty well when you were in practice ?
—Yes, fairly well.

10,534. It would be very interesting if you could give us an indication, or a statement in as much detail as possible, of your annual work and annual outlays and and remuneration, as indicating what the income of a doctor may be under present conditions in Lewis ?
—Well, I was in a partnership in the town, and that complicates the situation. I would not feel at liberty to do so. My partner will probably be here to-day, Dr Mackenzie, and so far asI am concerned, he is at perfect liberty to give any information of that sort.

10,535. It would be useful to know how far the doctor’s income is to be augmented from State sources to make a livelihood ?
—As far as I see, outside the burgh of Stornoway, I don’t think there is any essential fact that perhaps I could not tell you now. I think the essential fact is that we get ls. a mile, when we get it, from the fishermen.

10,536. You recognise the problem is different in a town with a surrounding district where a doctor can shoot out into the country to do part of the work in the surrounding district. The problem in that case is a different problem from that of an isolated country district where the whole medical income is in the hands of one man ?

10,537. I think the Committee are groping pretty successfully amongst the methods of dealing with the country areas. I am not at all so clear myself as to how to deal with the town areas. We had the problem before us in the Mainland repeatedly ?
—What sort of question would you like to ask me?

10,538. As to the number of your country visits ; what you were able to get for them, as to the distance you had to travel ; and as to the means of travelling. It would be of interest to know how many visits you had beyond three miles ; how many between three miles and five miles ; and how many between five and seven ?
—It would be quite easy to get that from our books, I am perfectly certain. I don’t see any reason why Dr Mackenzie should not be able to give you this.

10,539. It would be valuable if you could make up a statement of that sort. With regard to question 34——suggestions by the local doctors,—are these some things that are going to come before us in the course of the day ?
—I assumed that they would be before you in the sending in of the replies.

10,540. With regard to the nurse, I wonder if the problem is much different here in Lewis from what it is on the Mainland? The nurses probably are Miss M‘Phail’s nurses ?

10,541. They are trained in Govan, are not they ?
—Of those we have in Lewis some have been trained in Govan, one or two have been trained in a general hospital, and one or two have been trained here in the local hospital.

10,542. The standard of training for your district mainly is the Govan standard ?

10,543. Are these women who have gone from Lewis and come back again ?

10,544. Is that the best sort ; they have the local knowledge and atmosphere, and they know the people and the language ?
—Some knowledge of the people is essential, but for certain elements in their work I would like to have a stranger among them occasionally.

10,545. What would be the advantage of a stranger, and what class of case would a stranger be of advantage ?
—It is probably more difiicult to put it in a definite answer. I think it is always an advantage when people come in contact with strangers. Native persons sent away to get six months’ training are quite as good as strangers who have the same training, but they may be more tolerant to the conditions than we would like them to be. Besides nursing the individual patient, we always look to the nurse to give hints in practical hygiene inside and outside the house, and it is quite possible that a sensible stranger would be of advantage if she were tactful, but some of the natives do splendid work.

10,546. Do you think that the original environment of the girls before they go to learn nursing is such that even with proper training away from home they would still be under the infiuence of their old environment and not give sufiicient instruction to the people when they come back?
—If you give a selected Lewis girl a three years’ training in a general hospital, I will back her against anybody to send out to these houses.

10,547. Then you reply as to the undesirability of having them all from Lewis really rests on the assumption that they would not get an elaborate training when they were away. lf she got a good training the Lewis girl would be the best ?

10,548. Do you think that a considerable period of training of the Lewis girls away from home would make them too fastidious and make them unwilling to accept the conditions the Govan nurses put up with at present ?
—No, the conditions of the district nurses are quite good except as to salary and a dwelling, sometimes.

10,549. But where they have to live in the patient’s house ?
—Very seldom. They may have to pass a night now and again in a patient’s house.

10,550. It is not the custom here that the nurse should live in the patient’s house? In Lewis the habit does not exist to any great extent of the nurse living in the house?
—No, not to any great extent.

10,551. Not even in maternity cases ?
—No, she is only a night in the house on occasions.

10,552. (Chairman.) We had evidence on the Mainland that the nurse not only lived in the house, but milked the cows, and that sort of thing, in Sutherland ?~~I am quite aware of that. That does not exist in Lewis as a regular practice.

10,553. (Lady Tullibardine.) Do you find that the nurse if not sleeping in the house can give sufficient attention to satisfy the family ?
—The people are satisfied because they don’t expect more., but from my point of view, it is not enough.

10,554. You don’t think she gives sufficient medical skill ?
—Of course in a confinement a woman likes to have a nurse if she can afford it for a week or more. Here, under the present conditions, these nurses are with the patient until the crisis is over, and they simply go and visit once or twice a day after that. In exceptional cases, where there is no help in the house, I understand some of them give help ; then they are bound to do it. The system, generally speaking, is that they are with the patient until the crisis is over, and then they simply visit twice a day after.

10,555. Do you think that that means that the patient gets sufficient nursing attendance ?
—No, but is better than nothing. If you wanted sutficient nursing attendance on this island- I mean for the nurse to live in the house you must remember there are 30,000 people here, and it is the only part of the Highlands where the population has been increasing during the last few years—if you wanted a sufficient nursing service to meet the suggestions made by your Ladyship, you would require to have three times as many nurses as you have at present.

10,556. The reason the nurse does not stay in the house is not because you think it undesirable, but because she has other cases going on at the same time ?
—Yes, that is so.

10,557. How do the people get help in the housework ?
—The nurse helps to some extent while she is there. Of course the people have to depend on their own relatives for help in the housework.

10,558. Would they give anything to a neighbour for coming in to help?
—There is a certain fee exacted ; I think it is

10,559. That. is a fee to the neighbour ?
-No, to the nurse. The Committee gets the fees.

10,560. What I wanted to know was, is any fee given to a neighbour to help ?
-I am assuming that in most of these houses there are generally two women. Lewis is a thickly populated place and the houses are thickly populated, so that as a rule there is not any serious want of help and the neighbours are always willing to help.

10,561. You mean there might be one or two families living in one house?

10,562. Then I suppose it would be difficult, or practically impossible, for a nurse to be accommodated ?
—Practically. If that had to be done we would have to rely entirely on our local nurses, and possibly, as Dr M‘Vail said, if they had sufficient training they would get fastidious and would not be satisfied with that.

10,563. (Dr M'Vail) Are you satisfied with the training that the nurses get going to Govan ?

10,564. Would you like a little more elaborate training or a much more elaborate training?
—I think under the conditions we are, they should have a full training as well as an obstetric training.

10,565. A training of the nurse into habits of hygiene would naturally make her a guide to the people in their own homes ?

10,566. You don’t think that that would have any accompanying disadvantages in making her, as one might say, too big for her place
-No. I am assuming that she is practically a visiting nurse.

10,567. We heard on the Mainland, and I was struck with it, of the reserved character of the Highland people—their hesitation about having people whom they did not know. We heard about their dislike to having a stranger coming in and seeing their household affairs. That, of course, would not apply nearly so much where the nurse was not living in the house. Would it apply in Lewis? Are the people of the same character?
-There may be something in that, but they have got so accustomed to the nurses that I think any feeling of that sort has been dissolved long ago.

10,568. So that you are perfectly clear that with increased training of the nurses there would be a decided improvement in the health of the people and in the management of illness ?

10,569. You would not expect any real difficulty in the shape of objection of the people to having these women in their homes ?
—No, that is so.

10,570. The nurses would not be inclined to pay so much attention to their collars and cuffs and caps?
-There are always some like that.

10,571. You are rather of opinion that there is in addition to all that, room and desirability to have more doctors. In addition to having telephones and telegraphs if and improved travelling facilities, and other conveniences for medical attendance, you think that if you are to have the medical work properly done in Lewis, you would need to have more doctors? I am not asking that with the view of cutting down the present incomes of the doctors. Are you satisfied that there should be more ?
—I have considerable delicacy in speaking with regard to the parish of Stornoway, but with regard to the other parishes, I think that probably it might be found that the parishes of Uig and Barvas might need a rearrangement, with possibly an additional doctor. Of course, even with the best system of nurses, motors, and telephones, and so on, the distances are very great, and in some parts the population is high, and I am inclined to think that an additional doctor on that side of the island might be an advantage—provided the interests of the present doctors were conserved, to whose incomes I hope to see a much-needed increase as a result of this inquiry.

10,572. On the Mainland one figure often came before us as the income that a doctor should have, after paying house rent and travelling expenses and outlays. What professional income would you here suggest for a doctor in an isolated place where he has the Whole practice for the area, and is responsible for the physical welfare of the people, after paying house rent and all travelling expenses and outlays, and also the cost of drugs - a net income —to maintain his wife and family, and to save a little ?
—I would put it at £350 to £400.

10,573. Do you think they make anything like that just now in Lewis. Would £300 be as much as the most of them make?
—I think they must make much less than £300 in Lewis, net.

10,574. So that when you say £350 to £400 you suggest a big jump?
—Yes, but I should hope that that would be the outcome of this inquiry.

10,575. (Dr Mackenzie) About this nursing question, you have already stated that you prefer trained nurses who do not reside in the houses, rather than poorly trained nurses who might reside in the houses ?

10,576. Is not it the case that in a large number of the townships in Lewis the conditions of housing are such that it would not be a correct thing to ask any nurse to live in the house for nursing purposes, say, indeed, if it were possible otherwise to have a case nursed in it?
-You could not in reason do it.

10,577. And it would be therefore important, even for the purely medical side, that you should have a better staff of visiting nurses, highly trained, than a larger staff of resident nurses who would be satisfied with conditions that in themselves should be intolerable ?

10,578. Is it the case that in a large number of the houses, the cows, and sometimes the sheep, are housed in the house along with the people ?

10,579. Even for confinements, it is important to have fully trained nurses, because in many of of the cases it is not a proper place for a woman to be confined at all?
-No, of course you have got to make the best of the conditions.

10,580. You made the statement just now about the cattle in the houses, that it still exists in the majority of the townships ?
—In all the townships, With some exceptions.

10,581. Don’t they go in by separate doors?
-Some do.

10,582. Do you think that these are fit places for the domiciliary treatment of tuberculosis in any form?

10,583. You can say, as medical officer of health, having been a practitioner here for a number of years, that in your opinion the great majority—very nearly all-of the houses are absolutely unfit either for the treatment of bone tuberculosis or pulmonary tuberculosis?

10,584. Is that putting it too strongly ?

10,585. Have you any cases of tetanus among the infants?
—It is practically done away with.

10,586. When you talked of the club system, and of the medical difficulties, you were not thinking either of the infectious diseases or of tuberculosis as among the diseases to be treated at home?
—I was assuming diseases would be treated at home when they could not be treated anywhere else.

10,587. These would be included, of course, among the diseases to be treated by the doctors '

10,588. Would you apply the club system to the treatment of them; would you include infectious disease in the remuneration the local doctors would get from the club system or would you put them directly for services done through the Public Health rates?
—Yes, I should think so. With regard to tuberculosis, if you got a hospital for them, the Public Health Authority certainly would have charge of the hospital, and pay for them if funds were forthcoming.

10,589. Would you not suggest that it would be a good thing to pay medical men for attending infectious diseases ?
-Yes, because by legislation the Public Health Authority must look after infectious diseases.

10,590 You would not propose to undo that, and to put all the attention on infectious diseases on the club fee ?
—No. I think that would be a good way of subsidising them, provided the funds were made available from imperial sources.

10,591. It would make the club fee an important thing for other purposes?

10,592. At the present moment your nursing system for infectious diseases is quite inadequate. You have had fifty-two deaths from whooping-cough last year. That is an enormous number of deaths ?

10,593 You have typhus with you almost constantly. It is really not out of the island for two years on end ?
—About that—perhaps not quite so bad.

10,594. Which nurses attended these ?
—They happened in the epidemic last year to be chiefly in one village, and the nursing was mostly done by the special "fever nurse."

10,595. How many nurses do you think you would required for infectious diseases, including tuberculosis for the moment?
—I think that probably we would be better with one nurse, with the power to draft in nurses as they are required. For instance, we have not required one since April. For tuberculosis the local district nurses would be the best.

10,596. You would not have constant employment for them, but you would like to have three or four or five to call upon as occasion demanded ?

10,597. How many beds are in the hospital for infectious diseases?
—Two wards with four beds in each.

10,598. You never have a case removed away from the outlying districts?
—Very occasionally.

10,599. You have twelve beds in the general hospital. Are you satisfied that the full use is being made of that hospital for local purposes ?
—For the last year or two or it has not been made full use of.

10,600. How many doctors have you in the whole island ?
—In the parish of Stornoway there are two and an assistant, and there are three in the outlying districts. That is six altogether in private practice. That is 5000 a head, on the average.

10,601. It comes to roughly 4000 people per doctor in the burgh of Stornoway, and about 5000 to 6000 people in the other places per doctor ?

10,602. You are quite certain that the amount of disease without treatment in these places is very much more than one man could attend to under the present conditions ?
—It ought to be.

10,603. In order to make the service more adequate, you would either have to increase the number of doctors, or reduce the number of cases that they would have to attend to?
—Yes. Of course with nurses here and there, and the provision of motor-cars, you could obviate that to some extent.

10,604. Suppose the local authority for Public Health developed its full resources, and dealt with all infectious diseases and pneumonia, would that seriously reduce the number of patients to the other doctors?
—Pneumonia is very prevalent.

10,605. If you got that dealt with through the Public Health Authority, either by subsidising the men or increasing the number of medical men, it would be much more possible for .medical men to overtake the sickness of the localities?
—Yes, it would.

10,606. (Mr Lindsay). Under the Insurance Act the Local Authorities are made responsible for the provision of sanatoria?

10,607. And then the Insurance Committee is made responsible for the treatment of insured patients ?

10,608. Do you not think it would be better that the Local Authority should be responsible for the sanatoria, not only for the treatment of insured persons, but for the treatment of tuberculous patients ?

10,609. That is what I gather from your answer to No. 13?

10,610. (Dr Mackenzie.) How many insured persons do you think there will be in Lewis ?
—I cannot find out definitely.

10,611. Have you any indication at all ?
—My figure is not official.

10,612. The total population is 30,000 ?

10,613. Do you think that there will be as many as 3000, for example ?
—I have been trying to find out. The nearest I can get to it is about 1200 for the island. I am inclined to think that there will be about 1000 round about the parish of Stornoway.

10,614. (Mr Orrock). You referred to the parishes of Barvas and Uig ; there are two doctors there. The doctor for the parish of Barvas has twenty-four miles to go, but the public road runs right through his district ?

10,615. With regard to the parish of Uig, the doctor has to go to the upper end of Uig, twenty miles away ?

10,616. Do you propose to have three doctors for these parishes ?
—There seems a fair case for the proposal with the proviso already stated as to emoluments.

10,617. How would you divide these two parishes ?
—Assuming they were to be divided, I think one should be sent up to the head of Loch Roag at Maivig, and I would propose to have one at Carloway, the present doctor to have his choice.

10,618. Don’t you think the parish of Lochs is more difficult to work than the parish of Uig ? The doctor lives on the north side ; he has to cross Loch Erisort, and there are four townships there. Would you have a doctor on the other side of Loch Erisort ?
—I was thinking of that. After all, he lives at Keose, within ten miles of any of his patients as the crow flies. The place is being opened up with roads and there is hardly a village to which he cannot soon go by road.

10,619. (Chairman) By trap or pony ?
—By trap.

10,620. (Mr. Orrock) With the dense population in that district, supposing the doctor were ten miles away from his residence and an urgent call came from the other side of Loch Erisort, would it not take many hours before he would be able to get there ?
—Yes. Of course on the face of it it certainly suggests that there should be one on the south side of Erisort; but such an urgent call as you have suggested might occur if you had three doctors there. As a matter of fact, in experience, these things very very rarely occur. Certainly, according to the number of patients that a doctor has in other parts of the country, it looks too much to have the whole of Lochs under one man, and only a strong and active man like Dr Cameron could do justice to it.

10,621. Then you would suggest that additional nurses be planted over the different populous districts ?
—Yes; but before we leave that I should say that I lay very much more stress on the question of motor transit, telephones, and telegraphs, and the bringing of the distant patient into reach of the doctor by reduction or abolition of fees, than more doctors.

10,622. Would you have cottage hospitals ?
—I would have a nucleus of cottage hospitals. At the nurse’s home I would have one or two beds where a special patient could be taken in for special purposes, but to multiply cottage hospitals throughout the island at present would mean tremendous expense for the upkeep. If you could have private cottage hospitals in every parish, I would be delighted, and they would be very desirable, but it would be a very expensive scheme. This is really a nucleus of cottage hospitals that I was suggesting in my evidence, with a couple of beds or so, with a central hospital in Stornoway.

10,623. (Dr Mackenzie.) About tuberculosis, do you think that any part of the great amount of tuberculosis in Lewis is due to the milk .?
—Yes, I am afraid it is.

10,624. Of course you have rather more than half of the whole of the tuberculosis deaths in the county, although your population is not quite half the county population. Anyhow, it is a very large quantity. You have a large quantity of non-pulmonary as well as pulmonary tuberculosis ?

10,625. And the modern view is that certainly a large part of the non-pulmonary tuberculosis is due to infected milk ?
—Yes, it has been my opinion all along that milk was a great causative factor in Lewis.

10,626. So that under the conditions in Lewis we may reasonably suppose not only that the cows are infecting the people, but that the people reversely are infecting the cows ?

10,627. The real remedy there is not to increase the doctors, but the removal of the patients, so long as they are producing disease, on a compulsory scheme. Do you think that would improve the service?
—Certainly, if we got a sanatorium on this island.

10,628. Do you think that any increase in the number of doctors or nurses, without touching the question of production of disease, will ever make an adequate medical service for Lewis ?
—No. Even if you give sanatoria, unless the houses are in a better condition, you are simply touching the fringes. I hope it will come that we will have a sanatorium for this island. If this a recommendation of this sort it would be of great advantage. A sanatorium on the Mainland is not sufficient.

10,629. You want a tuberculosis hospital and a sanatorium as well?
—Yes. The geographic conditions makes it absolutely necessary.

10,630. Do you think that the general conditions, that the site and so on, would be suitable for the treatment of the disease here ?
—Yes, I think so.

10,631. At any rate, regardless of that, you need an institution on the island itself ?

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