HOSPITAL COMMISSION.

New Zealand Herald, Volume XLI, Issue 12698, 29 October 1904, Page 6

HOSPITAL COMMISSION.

THE MEDICAL ASSOCIATION'S

CHARGES.

STATEMENTS BY MEMBERS OF

THE BOARD.

MORE PROFESSIONAL

EVIDENCE.

The sittings of the Royal Commission appointed (o inquire into matters connected with the management of the Auckland Hospital were, continued yesterday, the Commissioners being District Judge Ward- (chairman), Mr,' Richmond Beethsun, ex-S.M., and Mr, S. E. McCarthy, S.M. Mr. R. McVeagh.appeared on, behalf of Dr. J. Hardie Neil (who has made a number of charges against the Hospital Board and the senior medical officer), Mr. J. R. Reed (instructed by Messrs. Hesketh and Richmond) appeared for the Hospital and Charitable Aid Board, Dr Roberton appeared on behalf of the Auckland division of the British Medical Association, and Bj?. Collins (senior medical officer of the hospital) conducted his own case. Dr. MacGinsgor, Inspector-General of Hospitals, was present on behalf of his Department. "

THE CHAIRMAN OF THE BOARD.

Mr. G. J. Garland, chairman of the Hospital Board, continuing his evidence under examination by Dr, Roberton, detailed the various measures adopted during the past two or three years in regard to the treatment of infectious diseases. In reply to Dr, Collins, witness sajd that very tew infectious cases were treated at the hospital prior to his (Dr. Collins') appointment. ' Beyond what was known as the ■" plague" hospital, they only had the cottage, capable of accommodating about six patients. , He believed that there were over 100 eases between January, 1902 (when Dr. Collins took charge) and October of the samo year. In order to cope with the infectious cases in that year, the Board took charge of the " plague" building, drained it, and used it for infectious cases..- 1 " - ;'' : i' ...

Dr. Collins read a report which he furnished to the Board in October, 1902, dealing with the question of infectious diseases. , He pointed out tte extra expense (about £1155) already incurred in that year, in treating infectious diseases, and. warned the Board that it would have to nuke provision for the treatment of such cases. -

Dr. Roberton nsad a provision in the Hospital and Charitable Institutions Act, which provided that any person, seeking relief "dinaH ha liable to contribute a reasonable sum, according to his means." The witness said he considered a "reasonable sum"-was the average daily cost of maintenance in the hospital, and that was the basis adopted by the Board. The fees, however, were written off when the Fees Committee considered there Was reason for it. Some patients cost more than others, and these patients frequently did not pay anything. A suggestion had been made that a record should be kept of the cost of each patient, and that every patient, if his m<?*as permitkd, should be compelled to pay such coat. The Board considered that such a system would entail too mucfa book-keeping. The amount spent on the hospital buildings was, he thought, over ,000. No provision was made for depredation and interest on the cost of these buildings in calculating the average cost of patients. He recollected a deputation waiting oh the Board in reference to the introduction of a graduated scale of charges arranged according to the financial position of the patients. His idea of the scheme was to exclude people who could pay, so they would have to go ;to a private hospital. That was, the impression he gained, although it was not so stated. Under certain circumstances he favoured patients being charged according to their means, but the law would, in, his opinion, have to be changed. -Dr. Roberton If a millionaire was .treated, should lie only pay the same as the person- who could barely pay the 4s 8d per day now charged?lf a man who is opulent; contributes towards the upkeep of the hospital through the local authority, and' has to go to the hospital for treatment, or a member of his family is sent, it would be very unreasonable to expect him to pay more than another ratepayer who is not so wealthy. ; Dr. Roberton: But the Act provides for the payment oil a " reasonable sum aci warding to his means."

Questioned about the method adopted by the Board for recovering fees from patients, the witness said it was dealt with by a Fees Committee. The first notice sent out asked for settlement, the second for immediate payment,, and this was followed up, if no reply was received, by a man making inquiries as to the position of the defaulter. If thought expedient, legal proceedings were then taken. No hardship was intended by the Board. He remembered, since he had been chairman, that an order baud been given to cease the out-patient department, because it was growing to such, proportions as to become uncontrollable. The out-patient department had now been arranged so that it should be carried m by the Charitable Aid ! Committee. ■ , .

Dr. Roberton banded the notices sent out by the Board to patients to Mr. Garland,' who, on looking over them, stated that, four notices were sent out before legal proceedings were taken.

Dr.; Roberton: Legal- proceedings are mentioned on the second notice. How is that?—l suppose some people ate thickskinned. .

THE COSTLEY WARDS.

The Chairman inquired the reason of the sudden change of the Board in deciding to convert the Costley Wards into surgical wards. He pointed out that the advantages of the Costley Wards for 'the children, for whom they were originally built, had been expatiated. upon by Mr. Garland when they (the members of the Commission) visited the hospital, but since the absurdity of erecting an expensive operating theatre close to the wards had been pointed out the Board had made a sudden change. .;'.-' "" Mr. Garland said it was hoped at no distant date to sweep away the typhoid fever buildings, and erect in their place wards suitable for the children. That, he said, was in the mind of the Board, .'.'..•

* The Chairman: I hope so. The Chairman also inquired under what authority members of the Board gave notes to persons for- admission. - Mr. Garland said that only the chairman ever gave such notes, and he had only given four or five in cases where he was certain that the persons were in pain. -' The Chairman thought the practice was open to abuse. ■ "• Mr. Garland remarked that he could positively say there had been no abuse of the practice since he was chairman. Mr. Reed said he'would call Mr. Garland again later. AN EX-CHAIRMAN OF THE BOARD EXAMINED'. Alexander Bruce said he had been a memi ber of the Hospital Board for 10 years. He [ was chairman of the Board in Dr. Baldwin's time. He represented the borough of Devonport and the counties of Wai'temata and Rodney. He, had been a member of the Waitemata County Council for 16 years. He agreed t;^at the services of the" honorary staff had a considerable money value. Dr. Roberton : Do you think ; £2000 "year too high an estimate to place on the serv.l{*?„ °t }« 10 members -of the honorary statt —i do not suppose we could get the talent for bho money. -" Do you think it could be quailed by the work ot two men paid £700 a year each?Witness spoke of the time given by members of the Board. He thought a medical man would be useful on the Board in connection with the purchase of dings, the jhoice of resident officers, etc. He did not think it would be an advantage to separate the Hospital Board from the Charitable Aid Board. He did not think a medical man of experience would be able to give his time as

a member of the Board. He thought that the Board derived some advantage from having a medical adviser when he was chairman, but he thought 'the'best advice could be got from the combined honorary staff. Dr. Baldwin left the hospital in order to take up a Government position. Witness was opposed to the change to the present position of medical management, which was brought forward by Mr. Stiehbury. He was fully aware that the staff was opposed to the change. Witness did not know how the rale was introduced making the senior medical officer the medium of communication between the honorary staff and the Board. He did not remember how the latest code (A rules was drawn up. The rules were one of the most important parts of the hospital, and should be drawn up by the Board, with the assistance of the honorary staff. It could not possibly be done by laymen at a Board meeting in a satisfactory manner. INTERPRETATION OF RULES. Witness said that in'giving the senior medical officer power to attend the honorary staff meetings, it was his belief that the senior officer would attend only to give information, and not to take part in the business. He thought it would be a similar position to that held by the chairman of ths honorary staff 10 years ago, when he had a seat, at the Board meetings, but. did not take a part in the business. DR. COLLINS' POSITION. Dr. Robertou: Has Dr. Collins acted as financial adviser to the Board?—l could not say definitely if he has, but he has pretty well controlled the Board. In reply to Mr. Reed, witness said ne never considered the honorary staff as being under the senior medical officer. There could not be any suggestion that the change in the system of medical management was instigated by. Dr. Collins, who had not arrived in the country at the time. He believed that the majority of the members of the Board were influenced by public opinion, 'as expressed in the press. It was not wise to take much notice of every letter that appeared in .the newspapers.. He gave an instance in which. a complaint had been made as to the treatment of a patient at the hospital by Dr.. Collins. On investigating it he found there was no foundation for the statement. THE FOOD SUPPLIES. Witness did not know anythiug'about the food supplies beyond that tenders were invited annually for the supplies in different sections. Meat was one class, bread another, groceries another, the latter including; nearly everything that grocers sold. ■ The Chairman: Is there anything that a grower does not sell at times? (Laughter.) Witness said that the vegetables generally came from the Costley Home. Mr. Beetham said that, if ho remembered rightly, the Costley Home complained that all the best of the cabbages went to the hospital, and that they (the Costley Home people) got only the" outside leaves. (Laughter.) Examined by Mr. McVeagh, \ witness stated that he understood that all major operations would be performed by the honorary staff, as stated by rule 22. The Chairman : It is the grossest distortion to say that under the rule the senior officer has a right to perform any major operations that went into the hospital. Mr. Bruce : The rule is most emphatic. Mr. McVeagh : But that is not the construction that has been placed on the rule. : The Chairman: The construction put on. it is a direct violation of the ordinary rules of the English language.

THE BOARD'S INQUIRY. Witness said that he was present at the ordinary meeting of the Board on the afternoon prior to the evening of the special meeting at which Dr. Neil was called upon to resign. At the afternoon meeting Dr. Neil's suspension (which had taken place a few days previously) was referred to, and witness asked for the reason of it. The chairman of the Boa.rd said, " \ou will know to-night." Witness raid he had a right to know then, and the chairman said the reason was that Dr. Neil had been absent from duty for nine days. At the special meeting in the evening, the whole stress of the proceedings was laid upon the subject of White's operation. After statements , had been made by several medical men, Dr. Bedford and Dr. Mackdlar (the-..two consulting surgeons), were called in. What statements did they make?— Dr. Bedford pronounced distinctly in favour of the medical superintendent. Dr. Mackellar said the matter should never have come before the public, and that it should have been sent back either to the honorary staff or to the Medical Association—l forget which. A 'resolution- was then proposed?— Yes, that , Dr. Neil be called upon to resign. There was no discussion, and it was carried.' I voted against it because I felt that we should have heard both sides. At the following meeting of the Board a letter was received from Dr. Neil, declining to resign, and it was resolved that ho be dismissed. Someone ,-said that it would be impossible to retain both Dr. Collins and: Dr.,-Neil in "the. hospital. 1 admitted this," but I always considered that Dr. Neil should not have been subjected to the indignity of being called upon to resign without being first proved guilty.

EVIDENCE BY DR. McDOWELL. Dr. McDowell, the next witness, stated I that he joined the hon. staff in March, ' 1901, when the resident staff consisted of a surgeon, a physician, and a medical adviser. That arrangement was very satisfactory, and remarkably good results were obtained. The only objection he had, however, was that there was too much work for the two residents. He remembered outside dissatisfaction expressed on account of a fatality under an anaesthetic, during the absence of the senior, Dr. Inglis. There was no foundation for general charges of want of care, as he considered. Dr. Inglis, as senior Surgeon, quite competent to carry out the administration of all anaesthetics, and the treatment of cases. In regard to a proposal, originating in consequence of the dissatisfaction, to appoint a medical superintendent, the hon. staff, of which witness was secretary at that time, considered that Dr. Inglis should be advanced to the position, and another junior, appointed. From an economical standpoint the hon. staff recommended this course in preference to the proposal of the Board to appoint a senior superintendent at £500 a year. The Chairman: Besides the absurdity of building' a' house at a cost of £1500 for him when the Board's, funds were in a chronic state of impeuuniosity. POSITION OF THE MEDICAL 1 SUPERINTENDENT. ' Witness said the proposal of the Board to assign distinct surgical work to the medical superintendent was a novel one, and the staff felt 60 strongly on the subject that a deputation was appointed to wait on the Board. The. deputation was not successful. The- members of the hon. staff were opposed to . active work being delegated to the superintendent, and wanted to reserve to themselves the right of putting up fractures and doing major operative work. He was surprised to find the rule making the senior medical officer the- medium of communication between the staff and the Board tacked on to one of the other rules. The staff also objected and caused a letter to be sent to the Board, asking for a definition of the position. A reply was received, stating that all communications had to go through the senior medical officer, but if the Board wished to keep a communication private it would be handed to the senior officer in a sealed letter. This was derogatory to the staff, and an absurd condition of tilings.

REASONS FOR RETIRING. . Dr. McDowell said he retired from the hon. staff in March, 1903, and did not make application for reappointment, because he was not satisfied with the condition of management. He felt that the hon. staff was in a way subordinate to the senior medical officer,, and that too much responsibility was put on the hon. staff without any'control in the management. That was especially in reference to the epidemic of infectious diseases some time 'back, when the buildings were, unsuitable, and the resident staff was too busy at operations to go round the wards with the hon. staff. Dr. Roberton: If .satisfactory arrangements, were made, would you be prepared

to rejoin the lion, staff?—-Yes. 'I can. Ray on behalf of the profession, that it is a. position we prise very.much.

CONSTITUTION;. OF THE BOARD.

Dr. McDowell said the present constitution of the Board was unsuitable. He believed better men would be found if the hospital and charitable aid was separated. The Government should nominate suitable men, such as appointed visitors to the asylum, Mr. Justice Cooper, Mr. Ewington, and others. The medical profession should have representation on the Board. The tenure of office of the Board was too short. Going on to the question of tho hospital buildings, the witness stated it was inconvenient, to the hen. resident. and nursing staffs to have the buildings located . sonic distance away, and it also added to the expense of running the institution. Cross-examined by Mr. Reed, Dr. McDowell said he had no record in the minutes of the honorary staff, while witness was secretary, of the" question of the senior medical officer performing abdominal operations having been discussed. Witness had addressed letters direct to the Board, because he felt it was derogatory to'have to communicate with the Board through the senior medical officer. CROSS-EXAMINATION BY DR. COLLINS. Witness was cross-examined by Dr. Collins as to what might be termed, emergency operations. Ho had remembered Dr. Collins performing an operation on one of witness' cases in a case of urgency. Gastric ulcers could also be termed emergency cases under certain conditions; Peake's case was an emergency operation. Certain classes of eases which Dr. Collins specified would be considered major operations. Dr. , Collins : There was a surgeon on. the honorary staff, was there not, who systematically cut his telephone off at night? I do not know. Has the staff not tacitly agreed until the last few days with the interpretation put upon the term " emergency?"—l have always thought that when death was threatening the operation should be performed. Then I was not contravening rule 21 in performing these operations?—lf life was in danger, you were not. Witness said he considered more buildings for infectious diseases should have been erected in years past. He had formerly thought that for minor infectious diseases the building could have been erected in the hospital grounds. Now that the number of infectious cases kid increased so much ■he thought it would be better to have the hospital farther away. DR. SCOTT EXAMINED. Dr. Scott stated that he was an hon. surgeon on the hospital staff. He had occupied the position of chairman of the honorary staff for some time. He pointed out some defects in the hospital buildings and the old operating theatre. "There was," ho said, " really no operating theatre in the hospital at present. I '' The staff had expressed the opinion that better facilities should be provided, and the Board had fob. lowed out this advice by erecting the new operating theatre. The modern trend was in the direction of having separate theatres for septic and aseptic cases. Ho considered that there should be two, if not three, theatres at the Auckland Hospital. As. Hon. surgeon, he considered he should treat only the poor. Have you found any difficulty in getting people to go into the hospital?— There are two classes who do not mind going in the very poor and the fairly rich. The for-' mer know that they cannot possibly lose any money, &ad .the latter did not mind when they knew that they could get £50 worth of operation for £5 or £10. Those who fear to go in— their fear is very bitter—are i the comparatively poor, wi->. by being provident, have got a roof of their own over : their heads. 1 have known cases of people of 60 years of age say, " I will have to mortgage my property if I go into the hospital, and if I do that I will never have a chance of lifting the mortgage." Than, when these people do go into the hospital, they often have a terrible dread of remaining there owing to the expense.

THE QUESTION OF OPERATIONS. Witness considered members of the honorary staff should be appointed for a longer period. When the question of the appointment of the senior medical officer came up, the , intention of the Board, he believed, was that they should get a man specially qualified for emergency work. He had been very much surprised to hear the view expressed that the senior medical officer should.not perform major surgical work. He did not think the senior medical officer had performed any operations not in conformity with -the rule. The hon. staff had discussed the question as to who was to use the discretion as to the' advisability of performing operations, and they decided on the person on the premises. The, Chairman: The question is whether the rule authorises him to. do it. ' Dr. Scott: The rule does authorise him. Hie Chairman: We will form our own opinion of the rules. ;. - OTHER SUGGESTIONS. :

Continuing, Dr. Scott said it would be advisable to have a , uniform system of hospital management throughout . the colony, arranged according to the size of the institutions. It would give an opportunity for the promotion of deserving residents to higher posts, and would avoid trouble between Board and stalls. He favoured the appointment of assistant-sur-geons to the hon. surgeons. As an exMayor of Oiiehunga, he could say that the representative of that district on the Hospital Board was elected from a financial standpoint—one who would, see that as little levy as possible would be made on the local authority in the upkeep of the hospital. He estimated that the monetary value of the services rendered by the hon. staff to the hospital at £3600 a year, reckoning on two guineas a visit, with four visits a week. The hon. staff were thus, ipso facto, contributors to the j maintenance of the hospital.

THE WHITE OPERATION. Mr. Reed cross-examined the witness as to the White operation. He said he was visiting surgeon that week, and was communicated with by. Dr. Collins. Witness was iii bed, suffering from influenza, and could not attend, so requested Dr. Colline to operate, as he had the fullest confidence in his capabilities. He said he was oonverauit with the particulars of the case and the operation, and stated he had known, in a similar case, it was necessary to evacuate the bowels. Mr. Reed: It has been suggested that the .shock of the opening or the bowels is likely to accelerate the death of the patient That is half of the truth. The other half is that a surgeon who feared shock was perfunctory about the cleansing of the bowels, and he would have a larger proportion of deaths than one who disregards shock and thoroughly cleanses the peritoneal cavity. It was move surgical to risk deaths by shock than to have certain deaths following peritonitis. It would cause delay, but the results were much superior. Opening the bowels takes time and causes shock, but it is safer than closing up the wound without relieving the bowels?—ln many instances that would bo the casa.

hi reply to Dr. Collins, the witness said he did not think Dr. Collins had arrogated his position, but had not overstepped the position granted him by the Board. Dr. Collins: You have known me to do very difficult and trying work?— Yes. Have you always had confidence in my work? Undoubtedly. You have - heard" it said . that Wallis White had a 50 per cent-, chance of hits life dissipated? Yes. White was suffering from a duodenal ulcer. Would you take Sir Frederick Treves' word on such a case as an authority —Undoubtedly. He says very few such cases are operated upon successfully; do you know if that is so?-—I presume he is "right. Would that contradict' the assertion ot a 50 per cent, chance of life being lost?— Yes.

Mr. McVeagh: If the mortality were more than 50 per cent., you will agree that it shows the necessity of the surgeon losing no time and using every care and skill in the operation?— All other things being equal, time is of great importance, but what was of more primary importance was the proper cleansing of the peritoneum.

If tho mortality is 80 per cent.?—My contention still holds good. It was no good getting tho patient off the table simply to die of secondary peritonitis. You say you have incisions in the intestines similar to those made in this case?l have made incisions in the intestines, but I have not seen.the incisions in this case. _ "■ ■• ' - ."■' In this case two incisions were made in. the colon, within Sin of each other. Have you ever done that?-— don't know that 1 have. If you found the appendix normal, have you in such a case opened the intestine in two places within 2in to remove ecyhalla?—l don't know if that has .been done. It would be a legitimate course to pursue with the object of exploring the abdominal cavity. I could quite imagine someone opening the intestine within 2in, Could you suggest why it was done?— would suggest that possibly it was done because there was urging by someone else of the operation, who would perhaps do it because ho was pushed for time, and hadn't time to consider.

\ Do you suggest any other reason? |'While doing a thing it is difficult to find ' out exactly where you are and what you i are . doing i Witness, replying to another question, I said that the apex of the appendix was often I difficult to find. I DR. PURCHAS' EVIDENCE. i Dr. A. C. Purchas stated that lie was fori merly a member of the honorary staff. When : he first went on the staff there was only one I resident; After some time the Board appointed a second resident. The Board next ; decided to appoint a medical superintendent. 1 The staff opposed this, and as the Board ( held to its decision and appointed a superinI tendent (Dr. Floyd Collins), the staff re- ! signed in a body. The Medical Associaj tion supported the staff on being called, upon ■ to fall into line with the staff. I Mr. Reed : That was to boycott the hospital? Dr. Roberton: May I object to Mr. Reed suggesting that the medical profession had decided to boycott anybody? The Chairman: It would be its well not to do so. Witness, proceeding with his evidence, gave a short history of the subsequent changes. In, Dr. Baldwin's time, if the surgeon .for the week was not available for an operation, tho next in rotation was sent for. Witness did not remember any case. in which the superintendent failed to get one of the honorary surgeons for an emergency operation. He considered all urgent surgical cases should be treated by tho honorary staff. He did not regard a medical superintendent as desirable. The hospital should be worked by junior residents, under the honorary staff. He objected to annual .appointments of the staff, and did not think the Board should have power to alter rules in this respect without reference to some higher authority, such as the In-spector-General. When •he was on th© staff they had a very varied collection of members* on the Board—undertakersj and all sorts. ..'■•.- The Chairman: Undertakers! Witness thought that men who might be looking after little trade pickings out of the hospital should not bo on the Board. Dr. Roberton:. Are you serious in what you say?—l- am afraid I am. Mr. Reed (laughing): Do you suggest that •in regard to undertakers? Witness complained of the position- of the Costley wards. He said that when the plans were prepared they were submitted to ■ the honorary staff. The members of the staff, after spending a' great deal of time m considering them, advised that the wards should be "erected at the eastern end of the main building. They understood that the Board's architect agreed with them, but;, to their surprise, the' Board placed the wards in the present position. Witness after that left the staff in; disgust. " , The Commission, then adjourned., To-day Dr. Williams will be examined at his residence at Mount Albert, and the.ordinary sittings will be resumed at ten o'clock on Monday. - *s