Lochmaddy, 16 October 1912 - Dr Murdo Tolmie Mackenzie

13,679. (Chairman.) You are a. Graduate of Edinburgh University, and you have been twenty-seven and a half years here?
—Yes.

13,680. Before that you were Medical Officer of Health in the parish of Strath in Skye?
—Yes.

13,681. Your area embraces the whole of North Uist and the various islands connected with it?
—Yes.

13,682. There is no doctor whose practice overlaps your practice?
—No.

13,683. The population of your area is 3680?
—Yes.

13,684. Do you find that population too much?
—Not if they were gathered together in a smaller area. It is too much when it is widely scattered about.

13,685. Will you give us a list of the various townships and the populations of the townships?
—Yes. Lochmaddy, three townships, has a population of 350 approximately, and the distances from my residence are from seventeen to twenty-one and a-half miles; Sollas, four townships, has a. population of 420, and the distances from my house are from five to eight miles; Tighary, four townships, has a population of 560, and the distances from my house are from one to four miles; Paible, three townships, has a population of 650, and the distances from my house are from five to seven miles; Carnish, three townships, has a population of 400, and the distances from my house are from fourteen to seventeen miles. Grimsay, three townships, has a population of 320, and the distances from my house are from eighteen to twenty-one and a-half miles; Baleshare, two townships, has a population of 300, and the distances are from twelve to fourteen miles from my house; Locheport has a population of 160, and the distances are from thirteen to seventeen and a-half miles from my house: Heisker has a population of 100, and the distances are eight miles by road and from six to eight miles by boat; Boreray has a population of 100, and the distances are fourteen miles by road and three miles by boat; Trumisgarry has a population of 110, and the distance is fourteen miles from my house; the three Claddachs have a population of 270, and the distances are from eight to thirteen miles from my house. The distance is twenty-one and a-half miles to Kallin and Scolvein, and they are got at by road, ford, and footpath. The distance is twenty-one and a-half miles to Lochporten, and I have to go by the road to Lochmaddy and then take a rowing boat. It is seventeen miles to Boreray Island, and I have fourteen miles to go by road to Newton and then three miles by boat to the island. Heisker is got at by going six miles by the Atlantic Ferry and six miles by road to the landingplace. The proportion of my patients at distances of five, ten, and twenty miles from my house are equally divided; they will be a little less in proportion at the very long distances.

13,686. Can you tell us what proportion of your patients are within three miles of you? I ask you that for this reason, that three miles is looked upon as the distance that a doctor goes without getting mileage. What proportion of your practice do you think is within three miles?
—Tighary is four miles from my house, but a portion of it is within the three-mile limit. On the north side there is part of one farm that might come in within the three miles.

13,687. The roads are fairly good and suitable for wheeled traffic?
—Yes.

13,688. Have you many patients who live at considerable distances from the road 2
—No. As a rule the road goes right round the island. Of course the districts go off at a tangent. I have to go over moors to some of them, but generally speaking, the houses are near the roads, or near footpaths.

13,689. You have in North Uist several dangerous fords?
—Yes.

13,690. And you use them to a considerable extent?
— Yes.

13,691. They are dangerous, and more than once people have lost their lives?
—Yes. On the whole of them people have lost their lives since I came to the island.

13,692. How do you get among your patients?
—I drive and walk.

13,693. Do you keep a motor?
—No.

13,694. You keep three horses and some traps?
—Yes.

13,695. Would you find a motor a great convenience?
—Yes, for the Mainland. For the Mainland the thirty-four miles circuit would certainly be improved by a motor.

13,696. It would improve the medical service for the people?
—Yes.

13,697. You tell us that your practice does not warrant a motor here, but if in the public interests it was found expedient, you think that would be justifiable expenditure on the part of a public body?
—Yes, I should think so, but I may say that the people don’t like motors themselves.

13,698. Are there many motors here?
—Only when the sportsmen come.

13,699. The hotels don’t have them?
—No.

13,700. That is surprising. They keep them in Harris and they keep them in Stornoway?
—They will come to that ultimately.

13,701. You are Medical Officer to the Parish Council for which you get £100?
—Yes.

13,702. And you have 60 paupers to attend to for that?
—Well, there are 44 ordinary paupers and 16 pauper lunatics
—there are 17 actually, but one of them is boarded out on the island of Skye. There are 44 ordinary paupers and 16 pauper lunatics, and the pauper lunatics require four visits in the year.

13,703 . The Parish Council give you £100 for attending them. It is a large sum, but I suppose it is given to you to keep you in the district?
—I suppose it is, but it does not appear too much when you consider you have to make four visits to 16 lunatics and sign the books each time. The lunatics live at a distance from my house as follows: 3 between 3 and 5 miles 6 between 6 and 7 miles 2 between 8 and 9 miles 5 between 15 and 18 miles Besides attendance on ordinary poor, I vaccinate at 10 stations ranging in distance from 21 to 3 miles from my house, involving a minimum of four attendances a year at each station. All this is paid at the rate of £100 a year, which is inadequate.

13,704. You have a fee of £25 as Chief District Medical Officer of Health for the County, and £40 as Medical Officer to the Combination Poorhouse and Asylum at Lochmaddy?
—Yes.

13,705. That is a long way from you?
—Yes.

13,706. Your answer to 11 (b) is very much the evidence we have got from nearly all the other doctors in the Highlands
—that is, that you are in favour of fixity of tenure for the doctors, although you have not had any trouble yourself, but you think it reasonable and fair that there should be an appeal to the Local Government Board?
—I think it is a necessity.

13,707. Do you think it would help to improve the character and the number of doctors who would apply for these posts?
—I am sure it would.

13,708. In regard to vaccinations, your evidence is also the evidence we have got in many parts of the Highlands, that the people are really becoming defaulters so that they may have their vaccinations carried out by the parish medical officer?
—I don’t know that that is the reason that they are defaulters; they give the reason that they don’t want their children vaccinated when young.

13,709. Have you any conscientious objectors?
—None whatever.

13,710. In some parishes on the Mainland we found that nearly everyone was a conscientious objector?
—We have not that here. At one time
—and it still holds good
—the Board of Supervision allowed this parish, and I think some of the neighbouring parishes, to have their children kept till they were a year old before being vaccinated, but I am getting them out of that now and they are coming down to the six months.

13,711. Are the people nearly all vaccinated?
—Yes.

13,712. Have you various days for going to the various townships in your district?
—I had that at first, but I had to give it up; it did no good.

13,713. Why?
—Supposing I had a day for visiting a certain place, I found I had to go back the next day to a special case. I found it was just a waste of man and horse.

13,714. We had evidence from the parish of Ullapool that the doctor went away twenty-five miles once a week, and it worked very well?
—I tried it, but it broke down.

13,715. We are very interested to hear about the club system that we have been told about in this district. The system, as I understand it, is that the crofters pay 5s. per household and the cottars pay 2s. 6d.?
—Some of the cottars also pay 5s. I think nearly the whole of them pay nearly 5s. now.

13,716. Are the farmers included in it?
—The farmers pay from £5 downwards. The man who pays £5 has got something like fourteen servants, and I have to attend the whole of them for that sum.

13,717. I see it amounts to £112 per annum?
—Yes.

13,718. You say it is a bad system?
—Yes.

13,719. Do you think it is a bad system for the Public Health or is it a wrong system for the doctor?
—It is a wrong system for the doctor and it is doing no good to the Public Health. The doctor’s time and services are used up in very trivial cases; he has to go twenty or thirty miles to see a man who has got a gumboil, and possibly you may be needed to go and see a man with pneumonia at that time.

13,720. Do you think if there was a check fee besides the 5s. a year, where they would have to pay either a small fee for every visit or, say, half a crown for the first visit and no fee after that, that that would prevent these frivolous calls?
—I think a fee for each visit should be made.

13,721. What we are anxious to get at is to get a system that would induce the people to send for the doctor in time, and any fee that might be fixed would need to be a fee that would prevent them sending for a trifling case and not prevent them sending for fear of running up a bill?
— That is my opinion.

13,722. Take the case of a patient who lives twenty miles from you: manifestly he cannot pay you an adequate fee for your services. It is impossible for him to pay 15s. or 20s. for several visits. He suffers that disadvantage, while the man next door to you gets your visits for half a crown or so. What we want is a system like the club system, and it has occurred to us that this very system that is here might, with modification, be made to apply all over the country, but we have been told, just as you have told us, that when there is not a charge for every visit, that they are inclined to send for trivial causes. You find that a difficulty here?
—Yes.

13,723. Of course if it was universal there would be a great deal more work for the doctor; if the people could get a doctor without having to pay a fee each time, they would send oftener?
—Yes.

13,724. Do you think that generally all over the Highlands there is a good deal of sickness unattended because the people are afraid to send for the doctor?
—I have never found that they are afraid to send for the doctor here.

13,725. You have a different system here, but we have been told by doctors in other places that there are many cases that are not reported soon enough to the doctor, and some have not been reported at all, because they are afraid to run up a bill?
—Yes, I believe that is so.

13,726. So long as the doctor is protected and properly remunerated for his services, you see no objection to such a system, which would spread the cost more equally over the whole parish. I am not asking you to commit yourself to a club system as practised in the South, because in the North the circumstances are very different. I think in the Highlands the circumstances are exceptional, and it seems to me before you can get proper remuneration for the doctor and proper attendance on the people you must spread the cost of illness over more than the invalids themselves. That is to say, a man who lives near the doctor and a man who does not need the doctor very often should bear the cost of the medical service to the others. Do you see any objection to such a system?
—I am afraid that the man living near the doctor, and the man who might never require the doctor, might object.

13,727. Wherever it has been voluntary in the Highlands it has almost invariably broken down. If it was made compulsory, do you see any objection to a man who lives near the doctor paying towards the medical service for the people who live at a great distance from the doctor?
—In other words, he would be penalised because he is a healthy man.

13,728. Yes; he would bear his share of the cost of the medical service?
—It is a very Christian way of looking at it.

13,729. Have you an alternative scheme in your district?
—No, I have not.

13,730. On p. 4 of your statement you say that an alternative scheme is only just being tried in a part of your district and the result cannot yet be estimated?
—It was an alternative scheme that I tried, of getting 5s. per family and then charging a fee for every visit, giving them certain privileges for that fee. I put three proposals before them. The first was a payment of 5s. a year, entitling them to free medical attendance at my house, or if made accidentally when I had a consultation in the district; if sent for to go to the island 5s. per visit would be charged, and it would be reduced to 2s. 6d. if the patient met me at Carinish. The second scheme was, if a payment of 3s. 6d. a year was made, it would be 1s. 6d. for a consultation at my house, and 1s. for a consultation if I was accidentally in the district or in Grimsay, and 3s. if I was met at Carinish. The third one was that those paying no subscription should pay 2s. 6d. a visit, plus 1s. a mile for travelling expenses. This was proposed in the case of Grimsay, from which a. disproportionate number of frivolous calls were made. It will probably not be given effect to; but the friendly discussion over the matter may result in frivolous calls being avoided more in future.

13,731. You would never refuse to go to a man, and it would result in your being out of pocket?
—Yes, and the result would be that they would not send for the doctor.

13,732. It would result in the doctor bearing the cost of it himself. We want to devise a scheme whereby they will benefit and whereby the doctor will receive proper remuneration. We don’t think the doctors in the Highlands are properly remunerated at all. We want to devise a scheme whereby their position will be improved and at the same time the medical service will be improved. What I wanted to get from you was this, that if such a scheme as you have got here was developed and consequently more demands were made on the doctor, whether you would be able to undertake all the work in your parish?
—I would try it, at any rate. I am afraid it would get heavier than it is at present.

13,733. It does not apply quite so much to your parish as to the other parishes, because you have had the benefit of a club system, but in many parishes, we are of the opinion, the doctor is not called in as often as he ought to be, for various reasons; and if we devise any scheme whereby he will be called in more often, then it will be too much for him to do the whole of the work himself; but you don’t think in your parish that that would be the case?
—I hardly think so.

13,734. With regard to question 16 (d) in your statement, what is very much in our mind is that a combination of both systems would perhaps be the best. That is to say, that it should be a general charge for. general medical attendance, and a fee which would not prevent them sending for a doctor, but which will prevent them sending for him for a gumboil, or something like that, in addition should be charged?
—Yes.

13,735. In regard to confinements, do you charge extra for them?
—Yes.

13,736. And operations?
—I don’t charge extra for operations as I probably could not get a fee.

13,737. Do you supply all the dressings?
—I get them to get their own dressings after the first dressing as a rule.

13,738. It is only fair that they should pay extra for that, is it not?
—Yes, decidedly.

13,739. In regard to the arrangement of your day’s work, do you think it would be an improvement to your practice if there was a special fee for people who sent for you after ten o’clock in the morning; that is to say, that your orders should all be in by ten o’clock in the morning? We have had evidence from several doctors to the effect that if they could only get their day’s work arranged by ten o’clock in the morning it would facilitate very much the carrying out of the work?
—I am afraid I could not expect that.

13,740. You charge medicine in addition to the 5s.?
— I am supposed to, but I never get it. I never do it.

13,741. Do you dispense your own drugs?
—I used to. A couple of merchants here keep medicines, and I make them get their medicine there and I dispense it gratis. I save money by doing that; I mean, I don’t lose the value of the medicines.

13,742. Do the merchants charge for them?
—Yes, but I make them up.

13,743. They are able to recover their fees better than you could do?
—Yes.

13,744. Of course you have no bad debts, because the 5s. is collected by the factor?
—Yes.

13,745. Do you think 5s. is a fair sum to charge a crofter?
—No.

13,746. Is it too little?
—It is sometimes.

13,747. Do you think they could pay more?
—Yes.

13,748. Do you think they are fairly prosperous in this district?
—There is not much money in this district, but they are well off.

13,749. They have plenty to eat and drink, but they have not much ready cash?
—That is so.

13,750. What is the main source of livelihood here?
— They are true crofters. There are a few who go in for the lobster-fishing.

13,751. They don’t go to the deep-sea fishing or herring-fishing?
—There is very little fishing here at all.

13,752. Have they very good crofts?
—Some of them keep eight cows.

13,753. How are they off for milk in this district?
— Pretty well.

13,754. Are the children well fed here?
—Yes.

13,755. What do they get mainly? They could get better food than they are getting. They are taking too much tea. They sell their eggs here.

13,756. Do you find here, as they found in Ireland, that they sell their eggs instead of using them?
—Yes. I think they should use more and sell less.

13,757. You say about 15 per cent. of the people above the pauper line don’t receive medical attendance, and you think it is both carelessness and ignorance that is the cause of that?
—Yes.

13,758. I suppose it is mostly the old people?
—Yes, old chronics.

13,759. And they try to exhaust their own cures first ?
— They think their time has come; they are fatalistic.

13,760. Have you any cures where they adopt certain formulae which is pretty nearly related to the old witchcraft?
—We have none of that.

13,761. Have you any cases of the seventh son touching the patient to cure King’s evil?
—No.

13,762. Are there any cases in North Uist of the cattle living in the houses with the people?
—There are very few, if there are any. None have been drawn to my attention of late years, and I see none myself.

13,763. They are very much improved?
—Yes, looking at them, but I am sorry that phthisis should be so prevalent. Their houses are damper than they were.

13,764. Now about nursing, have you any nurses in your district?
—We have got two. One is a fully qualified nurse and the other is merely a maternity nurse.

13,765. Is that sufficient?
—Yes, but it is not necessary that we should have one as a fully qualified nurse. We could take another nurse.

13,766. Do these nurses act under your advice and instructions?
—Yes

13,767. They are under your control?
—Yes.

13,768. That is very much more satisfactory than if they were on their own?
—Yes. They are supposed to be under a Nursing Association, but they are under my hands

13,769. They don’t take on cases on their own account?
— They take on maternity cases.

13,770. Do they charge for maternity cases?
—They charge 5s. each.

13,771. Do they attend most of the maternity cases?
— Now they do.

13,772. They never send for you unless it turns out to be serious?
—The old “ skilly ” wife is still to the fore.

13,773. Are there any deaths due to the want of attention on the part of these unskilled people?
—There are very few Very few deaths have occurred, and there has been very little puerperal fever after them. I have always been very much amazed at that. Only severe cases are attended by the doctor now. The number of confinements attended by certificated or maternity nurses was about thirty-five, and the number attended by the doctor was ten. The number attended by uncertificated nurses only was about thirty-five.

13,774. Tell us about tuberculosis. Do you think it is increasing?
—Undoubtedly.

13,775. What do you think that is due to?
—Bad food to start with, and a lot of them go to the South and don't look well after themselves when they are there. They go into bad lodgings and get bad feeding there. There is no doubt that there is contamination. It is a curious thing that in the old times the Highlanders knew tthat consumption was contagious.

13,776. Did the Highlanders believe it was contagious?
—When I was a little boy, the people believed that it was contagious, and it was always a belief in the islands

13,777. Did they take precautions then that they don't take now?
—They used to burn the bedclothes and the clothing. In Skye, where I was brought up, they would not allow the clothes worn by a consumptive person to be worn by any other people.

13,778. They don’t do that now, do they?
—Yes, sometimes, but the Public Health Authorities come in and burn the clothes now or have them disinfected. Consumption has been increasing for some time. There have been twelve deaths already from phthisis in this parish this year, and there are nine at present on the list. The increase has been very marked.

13,779. How does that compare with your last ten years? Is it going down or up, do you think?
—For the ten years previous to 1907, I find that 13.735 per cent of the deaths were due to tuberculosis, and in the five years succeding that the percentage was 14.7 per cent. The death-rate at present for this year is 3.540 per 1000 for tubercular diseases. That includes phthisis and other tubercular diseases.

13,780. (Dr Mackenzie.) What is the death-rate in the parish all over?
—It varies. Last year I think it would be about 15.2

13,781. What is the rate per 1000 for the last three or four years of phthisis—of all tuberculosis?
—I did not take these. In 1908 it was 3.0379; in 1909, 2.5316, in 1910, 1.2658, and 3.540 per 1000 is the figure for this year up to date-the nine months.

13,782. The figures you have given us are for tuberculosis as a whole, not for phthisis alone?
—Yes.

13,783.. Could you give us the figures for phthisis alone for the years 1908, 1909, and 1910?
—I cannot, unfortunately, as I omitted bringing them

13,784. (Chairman) How do you do for an hospital here?
—We use the cottage where the man is laid up as the hospital.

13,785. You have no cottage hospital at all?
—No.

13,786. Would that be an advantage to you?
—A great advantage.

13,787. At the nurses’ house?
—There could be two or three beds at the nurses’ house, and one of the nurses could be in charge of them when not doing any district work.

13,788. You could get serious cases treated there and attended to much better than they could be attended at home?
—Quite so, but cases that don’t require immediate treatment, I have for years been sending to the Western Infirmary, Glasgow. When I came here first of all I had to do it myself, and I was at a great disadvantage.

13,789. Could you perform serious operations in these houses?
—You have sometimes just to do your best.

13,790. Under great disadvantages, of course?
—-Yes.

13,791. You take a holiday, but it is entirely at your own expense?
—Yes.

13,792. There are many doctors in the Highlands who cannot get a holiday, and that is a bad thing, not only for doctors, but for the public health too, you agree?
—Yes.

13,793. They have no opportunity of refreshing their views about medical treatment?
—No. That is a necessity.

13,794. We are of the opinion that a great many of the doctors in the Highlands are not properly remunerated. I think everybody is anxious that a reasonable living should be provided for the doctors in the Highlands so that good men would be induced to come here, who like the life, and would be glad to work here if they had a chance of making a reasonable remuneration. What sum do you think should be fixed as a minimum salary for a doctor practising out here?
—That is a difficult thing.

13,795. I suppose if it was £300 that that would be more than a great many of them have?
—Yes, but it would be too little.

13,796. I agree that no doctor should be asked to work for less than that?
—Yes. There are some who get far less than that.

13,797. Supposing it was necessary for you to have additional assistance, would you prefer an assistant under your control, or would you prefer to have an additional nurse?
—I would prefer an assistant.

13,798. So long as that is provided, of course, without entrenching upon your income?
—Yes.

13,799. Where would you put your assistant in this district?
—I should certainly have to keep him with myself. I don’t suppose we could look forward to having sufficient to keep an assistant outside.

13,800. I am not looking forward to you keeping him; but having regard to the public requirements of medical attendance, if it was necessary that there should be another doctor here, then the doctor should be procured, but it would be unfair to suggest that that addition should come out of your salary. Would you find it more convenient to keep him beside yourself or keep him in another part of the parish?
—I think it would be better to keep him beside myself.

13,801. Do you think the people would say the same thing?
—I don't know that they would.

13,802. They would like to have him near their own door?
—Yes.

13,803. Tell us why you think it would be more convenient if you had him beside yourself?
— He would always be at hand for operations; he would always be under my directions. If he was living away from me it is very likely that he would be taken advantage of.

13,804. Are you pretty well off for telegraph offices here?
—Too well off some times.

13,805 Are they telegraphs or telephones?
—Telegraphs. There is a telephone at Clachan, but the rest are telegraphs.

13,806. Would they allow you to speak over the telephones?
—My nearest telegraph office is six miles away from me. I had to pay 9d. for porterage on a telegram until I told the people they would have to pay their own porterage.

13,807. What do you say as to your general suggestions for the improvement of the medical service in the Highlands?

13,808. We found in a good many districts that they don't particularly want more medical men, but they want more means of communication and they want motor-cars and motor-boats and so on?
—Of course there are some cases where that would meet the difficulty.

13,809. You don't think it would be meeting the difficulty here?
—No.

13,810. You think it would be better to have an assistant here?
—Yes.

13,811. I think you have no doubt at all that the introduction of motor-cars as improvement of the medical service in the Highlands would be a good thing?
—Yes.

13,812. If it is necessary in the public interest it must be provided for the doctors if they cannot provide themselves with one?
—Yes.

13,813. You travel 8000 miles a year, roughly
—Yes.

13,814. That would be a small number if you had a motor?
—Yes, quite.

13,815. But it is a great deal to do with horses?
—Yes.

13,816. You pay 2600 visits in a year?
—Yes.

13,817. And the £112 is not anything like fair remuneration for that work, besides the travelling you have got to do, but these are the conditions under which you have got to carry on your practice here?-
—Yes.

13,818. What are your suggestions for the improvement of medical service in the West Highlands and Islands?
— I. It is unquestionable that there is not a sufficient number of medical men for the work, not so much owing to the amount of the population as to the scattered nature of the areas over which the medical man has to travel, and the difficulties and hardships incidental to this, rendering it impossible for him to properly overtake the work. Personally, I travel annually from 7500 to 8000 miles, and pay on an average 2600 visits a year. Four-fifths of the travelling and nineteen—twentieth’s of all this visiting is made for a remuneration of £112 per annum, being among the crofter and cottar class. Therefore, in most parishes it would be necessary to have more medical men, either as assistants to the parish doctor or as holding independent positions. The remuneration should be adequate to attract capable men who would elect to stay. At present, owing to the general poverty of the class that chiefly demands their services this is not so, with the result that the positions are very frequently occupied by two classes: (a) Young men recently out of college who make the appointment merely a stepping-stone to something better, who remain only a year or two—not long enough to become sufficiently acquainted with the idiosyncracies of the people, or the diseases that families inherit or are liable to. (b) Older men, who after perhaps a chequered career, fall back upon such places as a last resort and harbour of refuge. While to the capable man, who, from inclination or perhaps the force of circumstances, elects to spend his life in these regions, the most hopeful outlook before him is to die in harness, in case he dies of starvation when old age and decrepitude render him unable to continue work.

II. Owing to the poverty of the people, it will be necessary for Government to come to the rescue by giving an increased medical aid grant. At present, in this parish it only amounts to about £25 per annum, which goes to the parish funds. I am of opinion that Government assistance should take the form of a capitation grant in respect of the crofter—fishermen class, to allow modified fees to be charged against persons requiring the niedical man’s services. I am quite convinced that it is necessary to charge fees, as in the parishes where this is not done, and where a club system is in vogue, the medical man is worn out by attendance on frivolous cases, to the detriment of real illness. From a case I have before me I will give the Commission a sample of an everyday occurrence Wherever the “Medical Club ” exists in the Highlands. I have before me the following telegram received a few days ago :
—“ Wife seriously ill come immediately.” Well, this man’s house is got at from mine, first, by a drive of fourteen miles by main road, then three miles of dangerous fords, and afterwards two miles of a township road to a point where I have to strike off for about a mile’s tramp on the moor. On arriving at this point I was met by the brother and brother-in-law, who told me the patient had left her husband’s house the previous evening and had gone to her father’s, two miles further on, with a mud strand to cross. Arriving there, I was told by the parents the patient had left and had walked across the moor, and would probably meet me on my return, which she did. Now, that person was quite fit to have gone to my house by cart or gig, what she could not walk. But they elected the easier way and put the labour and expense on me. Here was a journey of 42½ miles performed by the medical man needlessly, and for which the remuneration was to be taken from a club fee of 5s. per annum. But that is not the most grave aspect of the business. It was quite within probability that on my return home I should have before me an urgent message requiring me to go to a serious case of confinement. I ask what is the mental and physical condition, to undertake such a case, of a man performing such an arduous journey. Is it such that the lives of a mother and a coming child should be allowed to be dependent on him? Do that mother and child get the attention they are entitled to look for? Emphatically no. I have, to this same district, in one quarter of a year not so long ago, travelled over 490 miles to visit three families (two brothers and a sister) — visits mainly unnecessary—for the club fee of 5s. a year. The opening up of telegraphic communication has practically quadrupled my work, while the “club” fee remains the same. I have therefore this year been constrained to intimate that I shall make a charge per visit to this district of the parish in addition to the annual club fee. How it will work remains to be seen, but a capitation grant from the State would allow the fee to be a modified one.
III. The appointment should carry with it a pension and be recognised as a branch of the Civil Service, the pension to be retrospective (if adopted) on the recommendation of the Local Government Board.
IV. The doctor should be provided with an official residence, free of rates and taxes.
V. There should be provision made against capricious dismissal by the Local Boards who are often swayed by personal feelings and prejudices. A central authority, such as the Local Government Board for Scotland, should have a say, not only in the dismissal, but also in the ratifying of the appointment of the medical man. Efficiency, local predilections, and prejudices are not always compatible, and in small communities the clashing of interests is not conducive to obtaining the best results.
VI. The medical man should have a free month’s holiday at least. This is absolutely necessary, and at present a holiday is a grievous expense to an ill-paid man.
VII. Each parish should have a small cottage hospitaleeven two beds would be a boonwhere urgent surgical cases could be taken for operation. I have had to operate in a hut on a case of strangulated hernia, where a clerk gave chloroform, and light was obtained from a tallow candle held by a neighbouring crofter, who fainted during the proceedings. This was before the advent of the nurses who can give more eflicient assistance, but the huts are still there.
VIII. Adequate nursing should be provided in all the parishes. Here we have now two, and they have quite enough to do. Another would be necessary if we are to eliminate the “skilly” nurse—and the sooner the better. Other parishes are worse off than we are. Voluntary subscriptions are uncertain, and we depend to a large extent on the Ladies Association in Edinburgh, who have done excellent work in assisting to provide nurses in various places; that deserves grateful acknowledgment.
IX. These nurses also should be provided with free cottages—one might have charge of the hospital,—be paid partly at least by a State subsidy, and be eligible for a pension. I humbly submit the foregoing remarks to the Commission. ‘ The circumstances are exceptional and will require exceptional treatment. Anything the Commission recommends that will raise the status of the Hebridean medical man will part’ passu act beneficially on the health and well-being of these communities—nurseries of hardy men and women, but at present, so far as proper medical attention is concerned, an opprobrium to the State.

13,819. Do you think that a check fee would prevent a lot of the unnecessary calls that you have?
—Yes, I think so.

13,820. What do you think the check fee should be, so that it would be a fee that would not prevent them sending for the doctor?
—It should be arranged according to the distance.

13,821. Do you think that would be a fair thing?
—I think so.

13,822. We want to see that everybody, so far as possible, has a fair chance?
—It is hard to say. A man who lived at Grimsay would prefer to pay a fee to having to walk down to my house all that distance. It might not be necessary for me to visit him at all.

13,823. We have had evidence from some doctors who say that when they begin practice they find that they generally send for them unnecessarily, but that they made themselves disagreeable and the habit broke off. You don’t make yourself disagreeable?
—I am afraid I don’t find my practice dropping off.

13,824. We will he interested to know how your fee turns out; whether it prevents them sending for you unnecessarily?
—I am afraid it is knocked on the head for this year. They have got their tickets. If there was any difficulty about it I would rather not have it.

13,825. Have you many insured people here?
—I don’t think there can be many. There will not be more than 120 or 150 at the outside, and they are chiefly farm servants.

13,826. You suggest here that there should be a combination, and that the doctor should be recognised as part of the Civil Service. I suppose many doctors in the Hi hlands find it very difficult, if not impossible, to lay aside enough for their old age?
—They must.

13,827. Are you in favour of a State service?
—I am, to a certain extent. I think I should be in favour of it for places like the Highlands.

13,828. Is there any other work a doctor could do in the various districts? Would you approve of him being the Registrar?
—I should not care about it. Some medical men keep an hotel.

13,829. Do you know of any who keep an hotel?
—I have known of them.

13,830. You know it to be a serious disadvantage in the Highlands that it is difficult for the doctor to get a house?
—Yes.

13,831. And the Parish Council has no power to build one for him?
—No.

13,832. You think it necessary in the public interests that the doctor should have a holiday occasionally?
—Yes.

13,833. And you approve of a small cottage hospital, as far as possible, being in every parish?
—Yes.

13,833A. And you believe strongly in adequate nurs ing?
—Yes.

13,834. You differentiate between the Queen’s nurses and the Jubliee nurses and what are called the Govan nurses, who have a shorter training?
—The nurses we have got are hospital-trained nurses. They are not Jubilee nurses.

13,835. They have their proper qualifications?
—One of them is a fully qualified nurse and the other has only got a maternity certificate. As long as we have got one qualified nurse we don’t mind, but we could do with another one.

13,836. And an assistant?
—Yes. It is not absolutely necessary to have both, but we could do with both.

13,837. I suppose you agree it is common knowledge that the rates in the Western Hebrides at present are so high that no more could be expected off them?
—That is so.

13,838. And any increased expenditure must be provided for from State funds or from some specially devised method of club payment?
—Yes

13,839. And a combination of both, I daresay, in your opinion, is necessary?
—Yes. .

13,840. (Lady T ullibardine.) If outside assistance could be given, which would enable a small uniform fee, say, of 2s. 6d. a visit, to be charged all over your parish, would you prefer that to a club arrangement with a uniform check fee such as the Chairman has mentioned? Would you prefer attendance per visit on a fixed scale, a scale, say fixed at 2s. 6d. with the aid of outside assistance, to a club system with a small uniform check fee?
—A club system, I think, with a fee per visit is the best.

13,841. That is the best, from your point of view?
—Yes. and I think from the point of view of the people it would be the best as well.

13,842. May I ask why it would be best from your point of view?
—Well, from my point of view it would be better having a capitation fee, and then I would be sure of something, and then I would get a fee at the same time. It would prevent my being sent for probably pretty often unnecessarily.

13,843. But I am assuming that you might be sure of something from outside assistance which would meet the difficulty of the club capitation fees. Supposing you were sure of a certain sum from outside
—supposing you were sure of some grant from imperial sources which might correspond to what you get from the capitation fee of a club system,
—then would you prefer a club system with a uniform check fee or a small payment per visit only?
—I would prefer a small payment per visit with a capitation fee.

13,844. The point being that you want to be of a certain sum?
—Yes.

13,845. In either case?
—Yes.

13,846. You said you would prefer a graduated check fee. How much would you propose as the maximum for a check fee for a distant visit 2
—That is a point I have not altogether settled in my mind. It is mileage, you mean?

13,847. You said you wished to charge a patient living at a distance a higher check fee than the patient living at your door, and I wanted to know how much it was you contemplated charging respectively to patients at a distance and at your door?
—I don’t understand the question.

13,848. Under the club system, supposing there was a system of check fees, you would not want a check fee to be uniform?
—I object to a uniform fee. What I objected to was that the person near at hand should have as much to pay as the person far away.

13,849. From the point of view of the person near at hand?
—Yes.

13,850. But, from your own point of view, if some outside assistance were iven to help you, would you then be ready to attend the distant patient for the same check for as the near patient?
—With an assistant I would be inclined to make the fee uniform then.

13,851. Would that remove your only objection to a uniform check fee .?
—It would hardly remove it; because I hardly think it fair that the man who lives far away should pay as little as the man near at hand.

13,852. The distant patient has the disadvantage that he cannot get you as soon as, or possibly not as often as, the nearer patient?
—Then, you would need to make the minimum fee sufficient to be remuneration for the longer distances.

13,853. (Dr Mackenzie). Supposing it cost you nothing to go there, or it cost the patient nothing for you to go, would you be quite prepared to charge the same fee to that patient as you would to the patient near at hand?
—That would be a grant for equalising the fee all over the parish.

13,854. (Lady Tullibardine.) Would you think a check fee for every visit preferable to a check fee for the first visit in an illnesss?
—I would have it for every visit.

13,855. One doctor suggested to us that with a club system he would prefer to give the first two or three visits every year free, and any visits over and above that number he would charge for?
—I am afraid there would only be the first two or three visits to pay then.

13,856. They might get insufficient attendance then, you mean?
—Yes.

13,857. You don’t think that a fee for the first visit only would meet your difliculties?
—No.

13,858. Would it be difficult to define what the first visit was? I mean to say, might the patient want your first visit to count as the first visit to the whole house, whereas you might want to charge a first visit to another patient in the same house?
—I should think if there were more than one patient in the house at the time that the first visit would be for them all.

13,859. Would you see any difficulty in chronic cases in making out which was the first visit?
—I don’t suppose I would.

13,860. Would you prefer a check fee of a shilling for every visit to a check fee of say 2s. 6d. for the first visit in the illness?
—Yes, certainly I would, unless you had a small check fee for the visits after the 2s. 6d. visit.

13,861. Your point is that you want payment for every visit even if it is a small fee?
—Yes, and if you like you can make the first payment higher and the rest lower, or you can have them all the same.

13,862. Can you say what you think would be a fair check fee for the people of North Uist, a fee that would not keep the patients rom sending for you when necessary, and yet a fee that would prevent trifling calls?
—That would depend greatly on how the doctor was to be paid. Are you assuming that he is to get anything from an outside grant.

13,863. Yes, I am assuming that and a club subscription in addition?
— Yes, and you want to know what the check fee should be in addition?

13,864. Yes, having regard to the resources of the people?
—I should say about 1s. 6d. 13.865. Would that be what you would suggest as the minimum fee for the first visit?
—I would have it 1s. 6d. for every visit.

13,866. Will you tell me if you think that under the present system you are getting at your cases of illness early enough to satisfy you?
—You mean getting notice to attend them.

13,867. Yes?
—I cannot say I am getting that in the majority of cases.

13,868. To what do you attribute the delay in sending for you?
—Want of knowledge, and probably laziness.

13,869. Do you find that the presence of the nurses tends to make the people send for you earlier?
—Yes, it does, and again the presence of the nurses saves me a great deal of work. It is only maternity cases they can attend to themselves. They attend to a cut finger or anything like that that they can bind up.

13,870. There are some cases that they take quite by themselves?
—Yes. They have got my instructions, of course. They are simple surgical cases.

13,871. Do the nurses just take cases requiring first aid, such as a cut finger, or do they take cases that need more than first aid?
—Just first aid, and dressing the wound again if is not sufficiently severe for me to see it

13,872. You might start the thing and they would carry it on afterwards?
—Yes.

13,873. You told us that there are some members of the club who pay a much higher subscription than others?
—Yes.

13,874. Do you think that that is a satisfactory plan, to have a graduated scale of subscriptions in a club system?

13,875. Because you are required to attend more people for the higher sum?
—Yes.

13,876. Are you of the opinion that these people could afford to pay a higher subscription?
—Yes, I think they could. They are quite able to pay it.

13,877. Would you suggest as an improvement in the medical service here, that the people above a certain income or rental limit should be asked to pay a higher club subscription, or would you prefer to see them left out of the club altogether?
—The Insurance Act may possibly have an effect on these people who pay a higher sum. They are mostly farmers who pay these higher sum, in respect of the persons they employ.

13,878. And therefore they won’t continue to pay for them in your club?
—It is hard to say what they will do. They may withdraw their subscriptions altogether from the club.

13,879. Would they be inclined to withdraw them for themselves and their families?
—They may do it. It is purely on account of their servants, I think, that they do subscribe.

13,880. Are the servants’ families not included?
—Yes, but, unfortunately, very few of them have families. The farmers’ families are attended to by me for the club subscription.

13,881. Many of them being unmarried men, they won’t trouble to join the club for themselves?
—That is so.

13,882. Therefore the Insurance Act will rather seriously affect your present system?
—Yes, but whether it is for better or for worse, I do not know.

13,883. As a matter of principle, would you wish to see the benefits of the club system limited to persons paying a certain rental or having a certain income?
—I am afraid anything touching the income limit would not have very much effect on this island. They are nearly all under the income limit of the Insurance Act.

13,884. It would not be possible to classify them by occupation?
—They are all about the same. Those who are shoemakers, and so on, are crofters as well.

13,885. Therefore, any club system here in North Uist would have to take in all the population below the income tax limit?
—Yes.

13,886. Except the insured persons, of course?
—Yes.

13,887. Has any objection been felt on the part of the cottars to having their club subscription raised from 2s. 6d. to 5s.?
—I have not heard any.

13,888. There was no difficulty in making the change?
—I don’t know that they all pay the 5s.

13,889. Do you know what constitutes the difference? How is it settled whether a man is to pay 2s 6d. or 5s.?
—I think some of them volunteered to pay the 5s.

13,890. Is it the case that some of the cottars are better off than the crofters?
—I don’t think so. They have no occupation to make them any better off than the crofters. They possibly may have more money in their pockets at a certain time than the crofters have.

13,891. Do you think that one nurse could look after, say, a couple of beds in a little cottage hospital and do some district work besides?
—I think that a small cottage hospital would be so seldom occupied that the nurse, if you did appoint her, would have very little to do, and that she might be at least outside for district working when not required for the cottage hospital.

13,892. Would you be satis?ed with a cottage hospital that was merely an ordinary house without an equipment for an operating room?
—I think one of the necessities would be that it should have a place where an operation could be performed.

13,893. You regard that as essential?
—Yes.

13,894. You tell us that you have a fully-trained nurse, but she is not a Jubilee nurse?
—Yes.

13,895. Did you try to get one through the Jubilee Institute?
—No. We tried to get one from Edinburgh. Those nurses we had went away and we appointed the ones we have just now off our own bat, without looking to whether they were Jubilee nurses or not.

13,896
—

13,897. Does your fully-trained nurse ever stay in the houses of her patients?-
—She stays when she has got a case to attend to. I send her very often to cases and tell her she will probably have to stay a night or two.

13,898. Do you regard that as desirable that she should be able to stay in a house a week if necessary?
—Yes.

13,899. Provided there is suitable accommodation?
— The accommodation they have is not always of the best, but I find the nurse is always very willing to make herself useful.

13,900. Is she ready to make herself useful in the house if the mother is laid up?
—Yes.

13,901. Have you found it easy to get satisfactory nurses through advertising?
—It was not very easy. There was a while that we were without any. We got natives of the place, and a native of Benbecula.

13,902. Have you found those nurses ready to stay with you?
—Yes.

13,903. What exactly are the qualifications of the fully trained nurse?
—She has had three years’ hospital training and maternity training afterwards.

13,904. Can you tell us the sort of work that she is ready to do in the house if the mother is laid up? I mean to say, is she ready to do more than just to attend to the mother and the baby .?
—Yes. She will help to clean up and perhaps help to cook.

13,905. And perhaps see that the other children go tidy to school?
—Yes.

13,906. And do you regard that as important, that the nurse should be ready to give help of that kind if the mother is laid up and there is nobody else to help?
—It is most important.

13,907. (Mr Grierson.) I see here you say you have had no reason to complain of your relations with the parochial authority. Do you think it would be an advantage to the doctors in the Highlands and Islands if the District Committee of the County Council were made the authority rather than the parish?
—Of course, here it is the same area. I think it works pretty well that the County Council district should be the parish district.

13,908. And that the emoluments should come to the doctor through the County Council and not through parish as the district. Is that your idea?
—Yes.

13,909. Then you would not have an idea of making the area larger?
—How would you propose to work a larger area?

13,910. I presume you would propose to work it by a central authority, and the doctor would have assistants under him?
—I think the areas are sufficiently large at present to be worked by the doctors.

13,911. Speaking of this question of whether you would have an assistant or a nurse, I am rather interested in what you say in your suggestions for the improvement of medical service. You say “Here was a journey of fortytwo miles performed by the medical man needlessly and for which the remuneration was to be taken from a club fee of 5s. per ammm. That is not the most grave aspect of the business. It was quite within probability that on my return home I should have before me an urgent message requiring me to go to a serious case of confinement. I ask, what is the mental and physical condition, to undertake such a case, of a man, after performing such an arduous journey .? Is it such that the lives of a mother and a coming child should be allowed to be dependent n him ”? Now, if it is a question of maternity cases alone, would not thoroughly certificated nurses do you just as well as an assistant?
—They could not do everything an assistant could do. I would not trust a nurse to give chloroform.

13,912. They could do so much that would enable you not to go to these trivial cases or maternity cases where you were not required, and therefore enable you to do other things that a doctor must do?
—I am afraid it would not do.

13,913. You would not be inclined to trust a nurse?
— No. If anything called me hastily away from the island I have nobody to take charge.

13,914. In that case, however, a nurse as assistant would not be so valuable as an assistant?
—No.

13,915. Would it be any assistance to you if there was some central authority, probably the County Council, whereby you might get the assistance of a distinguished medical practitioner or specialist when you had anything serious, or for consultations or operations or other things?
—As it is, when I need a consultant I get one from Glasgow or Edinburgh.

13,916. If he was a Government servant, would it not be an advantage?
—Yes.

13,917. If he was a distinguished surgeon or dentist that was available like that, do you think that would be an advantage?
—Yes. Of course, it would take away the local medical man’s choice of a consultant.

13,918. It would only leave you as you were before if he was not paid from other sources; you would not be able to ask for him more frequently for the purpose of going round your cases?
—Yes.

13,919. I see you are not greatly enamoured with the extension of the telegraph system. From your experience here you find that your practice has been increased by it?
—No, not at present. If there was a safeguard, I would wish a further extension of the telegraph system.

13,920. If there was a telephone attached to it, and the Government gave facilities to the doctor and the nurses, and anyone who wanted to consult a doctor to speak over it, would that not be an advantage and a saving to you?
— It would be an advantage. I don’t know that it would make the work much less.

13,921. Friends of the patient could consult you over the telephone and tell you whether you had to go?
—Yes.

13,922. It would put you in better communication with your nurses?
—Yes.

13,923. And the nurse would be able to call you up and advise you as to rise of temperature or anything like that that she thought was important?
—Yes.

13,924. (Mr Lindsay.) I was very interested in what you said in regard to the increase in pulmonary phthisis We had evidence from one doctor that of these cases many of them were imported from the South. They had either been caused by the conditions in the South or else had been developed in the South, that they had been in bad lodgings or had bad accommodation
—that it was due to the bad accommodation of the domestic servants in the South. Is that your experience?
—Yes, especiall ammong the men. The women are well housed; the men house themselves.

13,925. The evidence we had was in the other direction altogether, inasmuch as it was the domestic servants that were coming back from the South with consumption?
— Female domestic servants?

13,926. Yes?
—I find that they are not so subject to phthisis as the men are.

13,927. Your experience is that it is the men who come back with phthisis?
—Yes.

13,928. There are bylaws applicable to North uist with regard to buildings?
—No.

13,929. You have no building byelaws?
—No, except that the buildings must be conform to the public health.

13,930. You mean to tell me that the County Council of Inverness-shire have no building bylaws for this district?
— Not that I know of. Everybody builds as he likes.

13,931. You conclude that the increase of phthisis to the insanitary principle on which the new buildings have been constructed?
—That is hardly the way I put it. What I meant by that was this, that the old houses built with the stones not closely together on one another allowed a free. circulation of air. They had a fireplace in the centre of the house which allowed a lot of smoke to per colate through the walls or through the wood, and it acted as a disinfectant in these houses. The houses which are being built just now are built with chimneys in each end The one end is the kitchen and it is pretty dry and quite sanitary, but the end that they sleep in has rarely a fire in it. It is plastered inside and out, and it has has no effective ventilation.

13,932. It shows us that there have been no bylaws applicable to the island of north Uist, and these buildings have been built without any regard to sanitation whatever and ventilation?
—They have got the ventilation right enough in principle, but the house gets damp for want of a fire.

13,933. The idea is that these houses have been built as the people saw fit to do it, without any reference to byelaws with regard to the building of houses?
—I would hardly say as much as that. Take my house; if you leave the room a couple of days without a fire in it the wall is quite damp. The crofters’ houses are much the same.

13,934. Speaking about the question of the area of medical service, your answer to Mr Grierson was
—and it does not apply to you here
—-that for those places on the Mainland, and the other districts, it would be a benefit if the control of the medical service was in the hands not of the Parish Council, but of a larger body?
—I should think it should be under the control of the Local Government Board.

13,935. Why under the Local Government Board?
— There would be more independence.

13,936. You think that we should be governed by a body in Edinburgh. When asking you this question I am granting you the right of appeal to the Local Government Board or some other authority. You would not put the control of the whole medical service of the Highlands into the hands of the Local Government Board?
—I don't mind being governed by the Local Government Board.

13,937. They are more of an autocratic body than a small body would be?
—I don’t think so.

13,938. Are their many able-bodied men enrolled in the Naval Reserve or the Militia in this island?
—There are a lot who are in the Militia Reserve, and a few of them are in the Naval Reserve. There are also a few in the Yeomanry and the Lovat Scouts.

13,939. What proportion do you say would be serving in that way?
—I don’t know that I can tell you that Probably there will be 300. That is from this parish There will be about eighty scouts, I should say, and perhaps a little over twice as many Militiamen.

13,940. It was simply to compare this place with Lewis that I asked that question. It does not obtain here to the extent that it does there?
—No.

13,941. (Dr Miller.) Your evidence has been so excellent, and also your paper, that there is really very little for me to ask you. About this industrial club arrangement that has been spoken about, I gather that practically the whole resident industrial people in the island are under a club arrangement with you?
—Yes.

13,942. At 5s. per family?
—Yes.

13,943. And that returns you £112 per annum?
—It returns more. It returns about £140. The difference between the £112 and the £140 is what the larger members of the club system pay.

13,944. Leaving out the larger members for the present, the industrial class’s subscriptions amount to about £112 per annum?
—Yes.

13,945. So that at 5s. a year you could not expect under any compulsory system any great addition for that class?
—I believe they would be able to pay a little more.

13,946. But at 5s. a head you would not get very much more?
—No.

13,947. Supposing that was subsidised by a Government grant to a similar extent, say, to another 5s. per head, that would give you an income of £220 per year?
—Yes.

13,948. That seems quite inadequate, doesn’t it, if you are to have the services of an assistant and nurses, and so on?
—I could not get an assistant for the difference.

13,949. For the £220?
—No.

13,950. There is some idea of giving you a travelling allowance, or some kind of consideration in respect of your travelling expenses. You have heard about the motors. Would that to some extent meet the additional charges?
—Yes, it would go so far.

13,951. Even with that, there would be a difficulty in your being able to keep an assistant with a secured sum of £220?
—It would not do.

13,952. So that, taking your island as a kind of model island, this 5s. seems to fall short of what would procure what is called sufficient medical attendance in the island?

13,953. It almost looks as if the 5s. rate is too small?
—Yes.

13,954. This, after all, is a model district, and you have got the kind of population that we are wanting to deal with, and yet the amount shown is too little to provide sufficient medical attendance; isn’t that so?
—Yes.

13,955. What sort of contributor’s fee would you think a proper fee?
—Do you mean in lieu of the 5s.?

13,956. Yes?
—I think they ought to give another 2s. 6d. They could pay another 2s. 6d.

13,957. Unless the State comes forward in a handsome the 2s. 6d. additional would not be sufficient?
— If you leave matters as they are under the present system, I think they could afford another half-crown. Let matters as they are, the doctor could not give them sufficient medical attendance, and it would not give the medical man an adequate salary.

13,958. I take it that you consider a check fee absolutely essential, not only for the protection of the medical man, but of the protection of the population?
—Yes.

13,959. That is in the interests not only of the doctor, but of the rest of the population who would require the services of the doctor?
—Yes, and in the interests of real illness.

13,960. (Dr Mackenzie.) How long have you been in the island?
—About twenty-eight years.

13,961. You have been a medical officer of health all that time?
—Yes, under the old Parochial Board.

13,962. Did you have this club system right from the time you started?
—Yes.

13,963. It had been organised by Sir John Orde?
—Yes; it has never altered.

13,964. It has never increased?
—It is quite the contrary.

13,965. Relatively, it is less?
—Yes.

13,966. You get £25 a year as medical officer of health. What are you expected to do for that sum?
—I am expected to see after all matters pertaining to sanitation, and, one of the worst jobs of all, the drawing out of an annual report; I have to get a clerk after I make out the rough draught.

13,967. You have no hospital here for infectious cases, of course, and anything you do with epidemics you have practically to do as a private practitioner?
—Yes.

13,968. You have to attend to all the cases; you have to see that they are isolated in their homes; and you have to see that any nursing is done from the public health viewpoint; .you have to look after the closing of the schools; you have to give directions with regard to disinfection of the houses
—and, in fact, you are intended to do everything that is necessary in preventing the spread of infectious diseases of every kind?
—Yes.

13,969 Has the Local Authority ever given you anything over and above the retaining fee of £25
—anything special for the actual treatment of infectious diseases?
—No, nothing whatever, except in this respect, that for the last two years they supplied anti-toxin for diphtheria, and they paid for bacteriological examination of swabs.

13,970. That is good enough as far as it goes, but it does not amount to very much?
—No.

13,971. How many cases have you attended within the last ten years of scarlet fever, roughly?
—I can tell you what I have had this year. I have only had eighteen this year.

13,972. How many would you have last year?
—I don’t think I had anything at all. I had a little diphtheria last year and one case of erysipelas.

13,973. How many cases of diphtheria?
—Very few; it is very rare.

13,974. When was your last epidemic of diphtheria?
— I have never had much diphtheria. There occurred twelve cases in Carinish in 1909.

13,975. With regard to scarlet fever, it is very rare; you have it nearly every five years, and it is a big spate, amounting to perhaps five hundred cases?
—Yes; but the number is not anything like that, though many cases go unrecognised owing to mildness.

13,976. Have you had any typhoid recently?
—No, not since 1910.

13,977. Any typhus?
—I have only seen one case of typhus in the last twenty years.

13,978. Recently your infection has been fairly low down?
—Yes.

13,979. In any case you have attended to them all, and you have never got anything from the Local Authority for it?
—Nothing except the notification fee.

13,980. But then you would get that in any case if you were a private practitioner. If all these cases or a proportion of them had been removed to an hospital, it would have been entirely at the expense of the Local Authority. The same thing is done by you as medical officer of health and private practitioner for nothing; they are getting it done for nothing?
—Yes.

13,981. It would be one source of increasing your income if you were paid for these cases?
—Yes. I have tried to bring pressure to bear on them with regard to these cases, but it has not done much.

13,982. Do you do any work for the School Board at all?
—A lot of work.

13,983. Youhave the general supervision of the sanitation of the schools?
—Yes.

13,984. You say that tuberculosis is increasing. Is it your general impression that phthisis is increasing or that general tuberculosis is increasing?
—Undoubtedly both are increasing.

13,985. What do you think it is due to? Has the milk anything to do with it? Is there more or less milk consumed now than there used to be?
—I have not been able to blame the milk hitherto. I have always thought of the question of bovine tuberculosis in any case that has occurred in a house, but I have never been able to satisfy myself that I have seen a case of bovine tuberculosis. I know that the rats have tubercle and the rabbits have tubercle; I had to kill a ram the other day because it had tubercle.

13,986. This is interesting. Have you recorded that case?
—No.

13,987. Have you actually examined the rats and rabbits?
—Yes.

13,988. Have you recorded that?
—No.

13,989. You are quite sure it is not plague?
—Yes, it is pure tubercle.

13,990. Do you think you can treat tuberculosis without additional institutional accommodation; are the houses, as a rule, even in this relatively good island, such that you can treat a case of phthisis at home with satisfaction in them?
—You cannot.

13,991. Your general idea would be that you do need a tuberculosis hospital or some place, at any rate, where you could have sanatorium, or relatively sanatorium, treatment?
—It is necessary. I don’t suppose the patients themselves are going to benefit one bit, but I think it is absolutely necessary for the protection of others.

13,992. Do you send any cases to the sanatorium?
—Yes.

13,993. Could you send more?
—The 15s. a week that they ask is prohibitive; we manage to get some cases in at 5s. a week.

13,994. Supposing 50 per cent. of the maintenance rate were paid
—and we have the expectation that it will be paid
—from imperial resources, could you use the sanatorium in Inverness-shire more?
—Yes.

13,995. You would find no difficulty in getting selected cases sent across?
—No.

13,996. I mean, there are cases in the island that would pay that amount?
—Not at the present moment. One little child is the only one I would like to send away.

13,997. Do you think this island is a good place for treating phthisis?
—It is the very worst place.

13,998. So that you would prefer to send the cases on to the Mainland?
—Yes.

13,999. Every case that you possibly could send you would prefer to send?
—Yes. The cases that come from the South go to pieces when they come home. I think it is due to so much moisture being in the atmosphere.

14,000. Is this a damper climate than Lewis?
—I should say it is. There is such a lot of saline matter suspended in the air that it causes a continuous dampness. I don’t know but that it is a good place to keep people from having phthisis. When infected cases come from the South they go rapidly to the bad here.

14,001. You have a great deal that is endemic?
—Yes.

14,002. About your Poor Law work, recently they increased your salary a little for the poorhouse?
—Yes.

14,003. That is because they made you responsible for the lunatic wards?
—Yes, quite.

14,004. It is an improvement on the whole?
—Yes, it is a most satisfactory thing.

14,005. From the ordinary standpoint?
—From every point of view.

14,006. You, as medical officer, prefer it?
—Yes. That is another case in point where the remuneration is not adequate.

14,007. Is any of that salary paid through the Lunacy Board? The Parish Council geta certain amount from the Lunacy Board, don’t they?
—Yes, but very little. A point that I would like to make here is that the present medical relief grant we get is only something like £23 or £24 for the parish.

14,008. Supposing you had an improvement on these salaries, your parish salary, your medical officer’s salary, your lunacy and School Board salary
—supposing you had fair remuneration, as it would be reckoned in a practice like this, and supposing you got tuberculous patients taken off your hands as far as possible, or concentrated for treatment
—do you think that one man is enough for this whole island and Grimsay?
—No.

14,009. What would you need to make it enough on these conditions
—I mean from the purely medical point of view, apart from the patients’ point of view?
—There is ample work for two men.

14,010. I think in answer to Dr Miller you said that you would prefer one man, an assistant, working under you, with a regular system of nurses working under your direction; at any rate in collaboration with you, and not acting independently as practitioners. If you got tuberculosis taken off your hands or concentrated so that you could handle it better, and if you had an assistant and three trained nurses acting with you, would you consider that a fair medical supply for an island like this?
—I would consider it a fairly good supply.

14,011. Do these nurses act as unqualified practitioners; do they take on cases on their own account, or do they act mostly under your directions?
—Under my directions.

14,012. You said that about 15 per cent. of the oorer people escape medical attendance. Has that been a tered to any extent since the Old Age Pensions Act came into operation?
—No; it makes no difference.

14,013. (Mr Orrock.) Are your rates high here?
—They are high enough.

14,014. Can you give us the rates, the total rates?
—The total rate is 7s. 5d. That is the local rate.

14,015. The county rates are not included there?
—No.

14,016. What are the county rates?
—I am not absolutely certain just now, but I think they are 1s. 2d.

14,017. That is 1s. 2d. upon proprietor and 1s. 2d. on occupier?-
—No; a half each
—7d. each. I am not absol utely certain as to the amount of the county rates.

14,018 With the deduction it will be practically 5s. in the £?
—Yes. Ten per cent. is taken off occupiers, and they are rated only on three-eighths under the Agricultural Ratings Act.

14,019. I think you said that the crofter here was purely an agricultural crofter?
—Yes, he does not mix up agriculture with fishing; at least very few do.

14,020. Is the kelp industry carried on there to any extent?
—Not much. Sometimes they get about £1000 or more into the island as the result of the tangle burning.

14,021. I think you said that the cottars in some cases voluntarily paid an equivalent fee to the crofters?
—Yes.

14,022. And that the cottar very often was in a better position than the crofter?
—I will not say he is in a better position, but he has more loose cash in his pocket. What he makes his living by is lobsters, and he gets his money for them.

14,023. With regard to the cottar, can you define what a cottar is?
—A man who has got no land, unless it is a few yards in front of his door which he has probably enclosed without the proprietors consent.

14,024. In reply to a question put to you by Lady Tullibardine, you said you thought that a patient living at a distance should pay more than a patient near at hand?
—Yes.

14,025. Then it was suggested that if a motor or some conveyance was sent to the doctor, then you would put the far
—away patient on the same platform as the patient near at hand?
—There would be more reason for doing so.

14,026. You were not thinking of you own time?
—I was, but I answered the question in that way in the interests of humanity.

14,027. (Chairman) Is there anything else you would like to say?
—Nothing except that I would like to say that the infantile mortality is very low. As an offset to the great preponderance of phthisis, the infantile mortality is only 34.373 per 1000 births.

14,028. (Dr Mackenzie.) That is probably at the moment the lowest in Scotland?
—That is an average for five years. Another point that is an offset to that is that the number of certified lunatics is 10.621 per 1000 of the population

14,029. Can you tell us the number of uncertified deaths in your parish?
—I can give you it for five years. The mean for five years was 16.864 per cent.
—from 1907-1911.

14,030. Have you any idea what it is in South Uist?
—Something like 45 per cent. It was in some parishes, I know, last year as high as 70 per cent. We have never had it here much larger than in 1907
—21.21. It has been as low as 11.6 in 1910.

14,031. Is it coming down?
—It keeps a fair average between 15 and 16.

14,032. They are mostly old people?
—Yes, and young children; but they are chiefly old people. The number of people that die over eighty years of age is extraordinary for a small place.