727LIVERPOOL.- SCOTLAND.

surgeon’s hands may be uusatisfactory in those of another,but it can nevertheless be stated absolutely that a largemajority of tonsils can be completely removed in their

capsules, and including the supratonsillar fossa, with the

guillotine, sometimes in one bite and sometimes with a

second application of the instrument. It must further be

pointed out that enucleation, at any rate as frequentlypractised, demands anaesthesia to the degree of completerelaxation, that an operation on the throat accompaniedby hæmorrhage under such complete anaesthesia is by nomeans a trivial one, and that, as Sir Felix Semon pointedout in a recent discussion, the severity of an operationshould be proportionate to the severity of the condition forwhich it is undertaken. In practically all cases of simpleenlargement in children the tonsil can be completely removedwith the guillotine, and even embedded tonsils can be

entirely shelled out by this method provided that the deepportion is not very adherent, a point which can be determinedby making the patient gag or by retracting the anterior

pillar with a probe. The tonsils which cannot be efficientlytreated by the guillotine, and which should be enucleated,are those surrounded by dense adhesions, and especially thosesmall, friable tonsils which are the seat of chronic folliculartonsillitis and full of caseous secretion. It need hardly besaid that these are not the easiest cases in which to performenucleation. I myself am strongly of the opinion thatenucleation should not be employed as the routine methodof removing enlarged tonsils in children, which after allform the large majority of tonsil cases. Nevertheless, weowe a great debt of gratitude to the advocates of enuclea-tion, not only for perfecting a very satisfactory method oftreating that minority of cases in which the guillotine is

inefficient, but even more for pointing out the bad resultswhich may follow from slicing off the superficial portion ofthe tonsil and for thus promoting a more thorough andefficient use of the guillotine.

I am. Sir. vours faithfully.Wimpole-street, W., August 27tli, 1912. HAROLD BARWELL.

FATAL POISONING DUE TO PICRIC ACIDUSED AS DUSTING POWDER

FOR A BURN.To the Editor of THE LANCET.

SIR,-With reference to the article in the South AfricanMedical Record of July 13th, referred to in an annotation inTHE LANCET of August 17th, would you be so kind as toallow me to state that picric acid is not included in any first-aid outfit supplied by the St. John Ambulance Association,and that the individual who described himself as an agent ofthis association had no authority to do so either from thisoffice or any of its South African centres or branches. Ihave received from South Africa a full report of thecircumstances.-I am, Sir, yours faithfully,

HERBERT C. PERROTT, Chief Secretary.St. John’s Gate, London, E.C., August 20th, 1912.

LIVERPOOL.

(FROM OUR OWN CORRESPONDENT.)

Sanatorium Benefits in Liverpool :The Local SubcommitteeWorking under Difficulties.

A TEMPORARY difficulty has arisen in the effort beingmade in Liverpool to put into operation the sanatoriumbenefits of the Insurance Act. The scheme, which wasoriginally propounded by the sanatorium subcommittee ofthe Local Insurance Committee, provided for the utilisationof the Consumption Hospital in Mount Pleasant as a centraltuberculosis dispensary, and the creation of two branch

dispensaries, one in the north end and another inthe south end, for which the subcommittee had inview eligible sites. Details of the scheme were forwardedto the Insurance Commissioners, but the reply of that

body was that no arrangements could be entered into beforeJan. 15th next beyond what were purely provisional. Inthese circumstances the subcommittee has been compelledto stay its hand. The subcommittee felt that to buy, or

even to rent on lease, buildings, and to fit them out as

tuberculosis dispensaries, with the bare possibility of havingto submit an alternative scheme at the beginning ofnext year, would be too much like a leap in the darkto be worthy of serious consideration. Thanks to an

arrangement which is on the point of being concludedwith the authorities of the Consumption Hospital, it willbe still possible for the persons insured under the Act to avail themselves of sanatorium benefits until a more permanentand far-reaching scheme can be established early in 1913.It is proposed that the Consumption Hospital should be used,not as a sanatorium, but as a tuberculosis dispensary, wherethe patients’ condition may be diagnosed, and where medicalmen, expert in tuberculous diseases, will prescribe ameliora-tive methods, which may take the form either of hometreatment or treatment in a sanatorium. In the latterevent the patient will be removed to the corporationhospital at Fazakerley, which is well adapted for workof this kind. It is not intended that the scheme shouldclash with or in any way trench upon the ordinarywork of the Consumption Hospital, so that the fact that theexpenses of the new patients will be defrayed out of otherfunds should not affect the inflow of charitable subscriptionswhich the hospital has in the past relied upon in considera-tion of its beneficent operations. Having regard to thelimitations imposed upon them by the provisional require-ments of the Insurance Commissioners, the feeling of thesubcommittee is that for the present, in fairness to thosewho have made financial sacrifice, their work should berestricted, as far as possible, to persons who are insuredunder the Act.

The Liverpool Infections Hospitals and Bed Isolation.In the medical officer of health’s annual report on the work

of the Liverpool city hospitals, Dr. C. Rundle, the medicalsuperintendent of the Fazakerley Hospital, says that in thelight of the very satisfactory results obtained at Fazakerleyby the system of bed isolation, it would appear that the

practice of rigorous asepsis on surgical lines has a value

equal to, or greater than, that of any accepted methods ofseparation by artificial barrier. The treatment of epidemicdiarrhoea by subcutaneous injections of sea-water is alsocommented on by him.

Sept. 2nd. __________________

SCOTLAND.

(FROM OUR OWN CORRESPONDENTS.)

Highland and Islands Medical Service.THE Highlands and Islands Medical Service Committee sat

at Kirkwall on August 26th, Sir John A. Dewar, M.P., inthe chair. Medical practitioners and other witnesses gaveevidence as to the difficulties to be overcome in providingefficient medical attendance for the comparatively well-populated islands, widely separated by seas, often dangerousto navigate. Few of those islands, even when constituted aparish, can offer a sufficient income to retain the services ofan efficient doctor, even although, as the committee wasassured, the Oicadian is always anxious to pay what fees hecan. The residences available for medical men were alsovery unsatisfactory. The fact that the medical man in thoselatitudes is so migratory is regarded as highly detrimental tothe public welfare ; but the remedy is not easy, for the parishfunds are in most cases already overburdened. Women doctorshad been tried, but the monetary considerations were no moresatisfactory to them than to men, while the conditions of lifewere too severe for them, and in certain cases the people hadnot had confidence in them. Several of the witnesses spokestrongly in favour of having trained nurses, more particularlyin the less accessible parts, and of having such places in tele-phonic communication with the doctor. Evidence was givenregarding a system of medical clubs in use in some of theparishes, and of the changes, mainly for the better, that havetaken place in the health of the people during the last fewyears ; also of the diminution in the death-rate from

pulmonary tuberculosis. Conscientious objectors to vaccina-tion are, however, in evidence here as in other places, andto such an extent that less than half the infants are nowa-

days vaccinated. The witnesses examined were Dr. R. P.

Heddle, medical officer of health of Orkney ; Mr. B. D. 0.Bell, medical officer of health of Kirkwall ; Dr. G. Sinclair,Kirkwall ; Dr. A. Lees Low, Stromness ; Dr. W. Park,

728 SCOTLAND.-IRELAND.

Sanday; Dr. M. L. McNeill, Holm ; Mr. Johnston ofCoubister, Orphir; Mr. Tulloch, Eday ; Mr. Gibson, Rousay;and Mr. Garrioch, Rendall.

Banffshire Doctors and the Insurance Act.On August 29th a meeting of the Banffshire Provisional

Medical Committee was held in Keith. The honorarysecretary stated that all the 29 medical practitioners in thecounty, also two whole-time men, had signed the comple-mentary pledge, and all who held contract practice appoint-ments had placed their resignations in his hands ; thatnone had accepted seats on the Provisional Insurance Com-mittee or otherwise acted contrary to the declared policy ofthe profession, and four, of them had declined nomination forseats on the Provisional Insurance Committee. The workingof sanatorium benefit and the question of remuneration for

domiciliary attendance was discussed, and the meetingunanimously agreed to attend insured persons suffering fromtuberculosis, subject to approval of any regulations that maybe made by the Insurance Committee, and on the follow-ing terms : (a) Reports 5s. (exclusive of visit or consulta-

tion) ; (b) consultation at surgery 2s. 6d. ; (c) visit2s. 6d. within burghs, or within one mile of doctor’s house,plus mileage ls. a mile (outward) beyond that ; (d) injec-tion of vaccine 2s. 6d. (vaccine to be at the expense of theadministrative authority and the fee for injection of vaccineto be additional to the fee for visit or consultation). The

meeting also unanimously resolved strenuously to resist anyattempt being made by the Insurance Commissioners to getbehind the general practitioners in the performance of theabove work. It was also resolved that it be an instructionthat, should anyone be asked by the Insurance Committeeto do the work for less remuneration, information be atonce sent to the honorary secretary, and that he at oncereport the occurrence to the Scottish Medical Insurance

Council. ., - .. -

Infant Mortality and Tuberculosis in Dundee.

In his annual report Dr. C. Templeman, medical officer ofhealth of the city, discusses the high infantile mortality inDundee, which is higher than that of any of the other largetowns. The total number of deaths in children under5 years of age was 939, the number who died in the first yearof life being 668. Calculated on the number of births

during the year the infantile mortality was 154 per 1000births. Prematurity and debility at birth come first as acause of death, then diarrhoeal diseases, and, thirdly, bron-chitis and pneumonia. With regard to the causes of the

high infantile mortality, poverty and the fact that inDundee so many of the mothers worked in factories (thelatest census showed that 23-4 per cent. of the marriedwomen of Dundee followed remunerative occupations)were the most potent, and also the fact that many ofthe mothers are so ignorant or indifferent to the simplestrules of hygiene and proper feeding. Dr. Templemanremarks on the house-fly as a fruitful source of infec-tion in typhoid fever, also on the dummy-teat or dirtycrust so frequently thrust into an infant’s mouth. He

regards as a menace to health the growing number of"conscientious objectors" to vaccination. During the yearJuly 1st, 1910, to June 30th, 1911, only 39 per cent.of the surviving children born during that period are regis-tered as being vaccinated. The death-rate during the yearfiom pulmonary phthisis was 16-783 per 10,000 of the

population, the deaths being mainly among members of theworking classes, and occurring mainly at the age when thewage-earning capacity was at the maximum. Along withMr. Newlands, H.M. Inspector of Factories, Dr. Templemanhad prepared a return showing the mortality from differentcauses in the various departments of the jute works of thecity, and it was found that the mortality from consumptionin persons over 14 years of age was greater by 6 per 10,000among jute workers than the mortality from the same causeat the same age in all the rest of the city.

The late -Dq,. Andrew Wilson.The death has occurred of Dr. Andrew Wilson, at the age

of 60, at North Berwick on August 25th. He was born io

Edinburgh, educated at the Dollar Institution, EdinburghRoyal High School, and Edinburgh University and MedicalSchool, where in 1876 he was appointed lecturer on zoologyand comparative anatomy. Afterwards he was editor ofHealth and examiner in the Faculty of Medicine for the

University of Glasgow. He was also lecturer on physiology

and health to the George Contbe Trust, and Gilchrist Trustlecturer. Dr. Wilson was a prolific writer in popular styleupon scientific subjects.

Aberdeen Royal Infirmary.At a meeting of the directors of the Aberdeen Royal

Infirmary, held on August 26th, Dr. A. H. Lister, who hasbeen an assistant physician in the infirmary since March,1897, was appointed a physician.

Sept. 2nd. ________________

IRELAND.(FROM OUR OWN CORRESPONDENTS.)

The Report of the Local Government Board. ’

THE annual report of the Local Government Board forIreland for the year ended March 31st, 1912, which has justbeen published, contains particulars concerning the adminis-tration of the Poor-laws and the public health work of thecountry. It is stated that on March 30th, 1912, there-were in workhouses in Ireland 38,100 persons. Of these,14,735 were in hospitals or infirmaries, 10,956 were agedor infirm, 2313 were lunatics, idiots, or epileptics, and 5097were children under 15. On the other hand, there were2569 children at nurse or boarded out. 1555 children under15 died in workhouses during the year, of whom 799 wereunder one year of age. The total number of deaths in work-houses was 10,084, of which 1445 were due to phthisis. Thereare still ten workhouses in which there is no trained nurse.There were 652,778 new cases attended by dispensary medicalofficers under the Medical Charities Act, and there were77,379 vaccinations or revaccinations performed. Thesalaries paid to dispensary medical officers amounted tof.104, 196. There are now 83 unions in which scales ofsalaries for the medical officers have been adopted. Thenotification of tuberculosis has been adopted in only 41sanitary districts. In 284 out of 309 sanitary districts stepshave been taken to carry out the provisions of the Dairies,Cowsheds, and lliilkshops Order.The Sanatorium Benefit and the Women’s National Health

A Association.Public opinion seems to be giving its support to the

position taken by the Conjoint Committee of the medicalprofession in reference to the Women’s National HealthAssociation. The county councils who are engaged in

inaugurating tuberculosis schemes are indignant to find thatthe Treasury -grants, to which they are entitled, have beendocked for the purpose of giving f.25,000 to the Women’sNational Health Association. As the association onlypurposes to carry on tuberculosis work for the countycouncils for a period of one year, and very few of the countycouncils have accepted its offers of help, it is, perhaps, notyet too late for the question of the grant to be re-

considered. In marked contrast with their lavishnesstoward the Women’s National Health Association is the

niggardliness of the National Insurance Commissioners in

regard to the fees to be paid by Insurance Committees tomedical practitioners undertaking domiciliary treatment ofpersons in receipt of the sanatorium benefit. The DublinInsurance Committee, after consultation with the localMedical Committee, proposed to allow a fee of 5s. for eachvisit at the patient’s home, and of 3s. 6d. for each attend-ance at the practitioner’s residence. The Commissioners haverefused to sanction these fees on the ground that they arehigher than the minimum fees s iggested by the BritishMedical Association. Lady Aberdeen, as president of theWomen’s National Health Association, has met the sanatoriumsubcommittee of the Conjoint British and Irish Medical

Associations Committee, and after a full and friendly dis-cussion it was arranged that three members of this sub-

! committee should be selected to advise with Lady Aberdeenso as to avoid future friction if possible.

Administration of Sanatorium Benefits.’ The secretary of the conjoint committee of the British and

Irish Medical Associations has made public the followingstatement as to the position of the medical profession inIreland regarding the administration of sanatorium benefits :-

The sanatorium subcommittee of the Conjoint Committee desire toE assure the public that the medical profession in Ireland are anxious to

give their most hearty cooperation in the administration of the sana-torium benefits, and to take their full share in the prevention of tuber-r culosis. The chief reason for the resignation of the medical members