CHRISTCHURCH HOSPITAL (REPORT OF INQUIRY INTO THE MANAGEMENT OF THE).

Appendix to the Journals of the House of Representatives, 1895 Session I, H-18

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1895. NEW ZEALAND.

CHRISTCHURCH HOSPITAL (REPORT OF INQUIRY INTO THE MANAGEMENT OF THE).

Presented to both Houses of the General Assembly by Command of His Excellency.

May it please your Excellency,— Christchurch, 16th July, 1895. In pursuance of your Excellency's Commission, dated the 13th March last, and afterwards extended by an instrument of the 2nd July, directing me to inquire into certain matters connected with the management of the Christchurch Hospital, I have now the honour to submit to your Excellency my report of the result of my inquiry, and of the conclusions at which I have arrived." In consequence, partly of illness, and partly of the engagements of Mr. Stringer, who has acted as counsel for the Hospital (Government) Department, I was unable to formally open the business before Friday, the 7th June. The first sitting for the taking of evidence was held on Monday, the 10th June, and the sittings were thereafter continued daily until Friday, the 14th; again on Monday, the 17th ; Wednesday, the 19th, to Friday, the 21st; Monday, the 24th, to Friday, the 28th; and on Monday and Tuesday, the Ist and 2nd of July. There have thus been seventeen public sittings, and about one hundred and eighty witnesses have been examined. I have also twice visited the Hospital, and have obtained such information as I could gather in that manner. At the opening of the inquiry the following counsel appeared : — Mr. Joynt, with Mr. Knight Hunt, for the following associations or persons : The Canterbury Liberal Association ; the Ballance Liberal Association ; the New Zealand Workers' Union; the Canterbury Branch of the New Zealand Eailway Servants' Society; the Women's Political Union ; the Women's Branch of the Orange Society; the Canterbury Women's Institute; Christina Cameron, late nurse in the Christchurch Hospital. Mr. Caygill, for the Progressive Liberal Association. Mr. Stringer, for the Hospitals and Charitable Aid Department. Mr. Loughrey, for the Hospital Board. Mr. Maude, for the matron of the Hospital. And at a later period there appeared : — Mr. Kippenberger, for the secretary and steward of the Hospital. Mr. Fisher, for Mr. Eichard Brown, chief wardsman. Mr. Eussell, for Dr. De Eenzi, late House Surgeon of the Hospital. Dr. Murray-Aynsley, the present House Surgeon, appeared on his own behalf. Mr. Joynt and Mr. Caygill, on behalf of the various persons and bodies respectively represented by them, put in two written statements containing charges or allegations respecting the management of the Hospital, upon which they proposed to lead evidence. These allegations are to a large extent identical with those contained in the letter signed " Tongariro," which has been by your Excellency's Commission specifically referred to me for inquiry, and where they are not identical they are yet so similar in their general scope and character that it will be convenient to take these documents together, and to consider seriatim the allegations made or implied in them before proceeding to more general matter. It is desirable to begin by stating that the writer of the "Tongariro" letter is Dr. Francis Mcßean Stewart, who up to nearly the end of last year had been for twelve years one of the honorarj' surgical staff of the Hospital, and who since his retirement from that position has been on the honorary consulting staff. I now proceed to consider the allegations in order, premising that " Tongariro " puts his specific charges in the form of questions, making no positive assertions except of a general character, which will be incidentally dealt with under other heads : — 1. The first question asked by " Tongariro " is thus expressed: "Is it true that the House Surgeon compels young girls to be present and assist in holding the limbs of men during delicate operations at which none but male attendants should be present ? " This is put in the form of a positive assertion in the other two papers, although a little modified in one of them. The answer is that none of the things alleged are true. Young girls are not compelled by the House Surgeon, or by any one else, to be present or assist on the occasions and in the manner alleged; and, further, there are no operations—and Dr. Stewart himself does not venture in his evidence to assert that there are—at which none but male attendants should be present. As a I—H. 18.

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matter of fact, the attendance of nurses at operations is left to the matron to direct and arrange, and the House Surgeon does not directly concern himself with it, provided that efficient assistance is available. The matron has excused probationers from attending on the one or two occasions when they have requested it. But undoubtedly it is part of the modern system of scientific nursing that those who are in training for that calling should accustom themselves to attend operations of all sorts, without for a moment permiting themselves to imagine that there can be anything impure or indelicate in any method by which scientific knowledge and skill are employed in the relief of suffering. The probationers at the Christchurch Hospital, one and all, I believe, regard their work in this light, and enter upon it in this spirit. In the one or two instances in which any of them have felt some reluctance to attend the class of operations referred to, it is clear that this reluctance arose, not from the spontaneous action of their own minds, but from indelicate and improper suggestions coming from another quarter. I refer to remarks made by Mr. Bichard Brown, the chief wardsman, who, brought up in an older school and unaccustomed to the scientific spirit of more modern methods, may have felt honestly, though unreasonably, shocked by a system which contravened his prejudices. At all events, he permitted himself to indulge in remarks to or at the probationers attending the operations which could not fail to be offensive to them, and were certainly very unbecoming on his part. A young nurse, endeavouring, without a thought of anything wrong, to learn her profession by rendering help at an operation, could hardly help feeling her position unpleasant when told by an elderly and experienced man that she " might make a nurse, but never a woman "; but it is not the nurse who ought to be ashamed of the remark. But remarks of this kind appear to have been the only cause (with the single exception that some nurses objected to the presence of the masseur at operations) of any difficulty arising from the attendance of probationers in the operating theatre. I have no hesitation, therefore, in dismissing the allegations under this head as destitute of any foundation in fact, as well as of any excuse that might arise from the ignorance of an unprofessional accuser, and I see no reason whatever for finding fault with the present system under which the attendance of nurses and probationers at operations is left to the matron. Under this system an office known as that of "theatre nurse" is held in rotation for a certain time by one person, whose business it is to see that the theatre and necessary appliances are got ready for the operation. The " sister "of the ward always attends, and one or more probationers, taken in rotation from the different wards, are also present for the purpose both of helping and of learning. The matron also is there, as a rule, to direct the order and disposition of the nursing staff, and to assign suitable duties to each, in doing which she would doubtless consider the age, capacity, and experience of each probationer, as well as the character of the operation, having regard also to the possible sensitiveness of the patient prior to the administration of the anassthetic. All this is matter for her discretion, and no good can come from the attempt to interfere with the control exercised by a lady who may fairly be credited with as genuine a concern for the moral delicacy of the young women under her charge as the writers of anonymous letters and their unseen prompters. 2. "Is it true that the House Surgeon issued an order that all patients must attend the Church of England services on Sundays, otherwise they would be punished by having their passes to visit their friends outside stopped ? " This is put in the form of an assertion in one of the other papers, and in the third it is more general, alleging that "The House Surgeon issues orders needlessly harassing to patients, and is generally arbitrary in his manner towards them." The fact, under this head, is that the House Surgeon did instruct the nurses to notify to the patients that those of them, except Eoman Catholics (and perhaps other denominations), would have their passes stopped if, being able, they did not attend the morning service on Sundays. And on one occasion he did actually tear up the pass of a patient for this cause. The doctor and matron seem to have thought it did not look seemly for patients to be idling about the corridors when the clergyman who gave his services to the Hospital could not get a congregation. The matron, on one occasion, wrote a memorandum on the back of an envelope for the information of the nurses in one of the wards, and this so-called order was stuck up by them in the ward kitchen. But the thing seems never to have been systematically insisted on, no steps being usually taken except to tell the patients where and when the religious service is to take place. Ido not think the practice of using any kind of pressure to induce the patients to attend a religious service can be justified. The cases of some English hospitals which have been quoted are not, I think, in point, since they, being supported by voluntary contributions, can frame their own rules, to which patients must conform or go out. But a hospital supported by the public purse is on quite a different footing, and no rules ought to be enforced but those necessary for the efficient working of the institution considered as a hospital. Ido not, however, think it at all likely that complaint on this head will again be made in connection with the Christchurch Hospital. 3. "Is it true that no applicant has a chance of being placed on the nursing staff unless she belongs to the Church of England? " The affirmative of this question is asserted in the other papers, one of which alleges that applicants have been refused on account of their religion. The evidence, however, shows that these statements are untrue, no question about religion being asked of probationers. 4. " Is it true, as a matter of fact, that all the recently-appointed probationers belong to the above denomination ? " This is not true, but the great majority beiong to it. How far this may be accounted for by the preponderance of that communion in Christchurch I cannot say. The only case in which a suggestion of unfairness has been specifically made in evidence is that of Probationer Maclaren. Her examination papers have been put in, together with those of some other candidates, for the purpose of comparison. Certainly the imputation of unfairness has not been proved. 5. " Is it true that probationers have been appointed without the knowledge or consent of the house committee, in whose hands, according to the rules, all such appointments rest?" This appears as No. 4. in the other papers, where the affirmative has been alleged.

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No such appointments have been made. Those candidates who, after three months' trial, are considered qualified to be placed on the nursing staff are, if there are vacancies for them, appointed probationers in the manner provided in by-laws 123 and 126. But if there is no vacancy the candidates so qualified may, if they are willing, be taken on by the matron as honorary probationers, receiving no pay, but waiting for a vacancy, and meanwhile learning their profession. For this practice the matron has a general authority. 6. "Is it true that no Irish need apply as probationers ? " " Tongariro "is the only one who has ventured on this suggestion. The answer to the question is that it is not true. 7. "Is it true that the House Doctor orders patients to be put on bread and water it they offend against what he considers the order of the wards ? " To this question—which stands as an assertion under No. 5 in the other papers—a note is appended to the effect that " The governor of the gaol dares not put the biggest villain under his care on bread and water without the permission of the Visiting Justices." It might have occurred to the writer that the reason why strict rules are necessary to prevent abuse of power in a prison is that the inmates of that institution are not at liberty to walk out whenever they may feel dissatisfied with their treatment. It appears that the House Surgeon has ordered patients on four different occasions to be put on bread and water. Two of these aggrieved persons were small boys, to whom the Hospital authorities might be regarded for the time being as in loco f mentis. The other two were men, one of whom was a prisoner from Lyttelton Gaol, and who, from that circumstance, might easily give more trouble than other patients, since he could not be readily expelled. It seems that these orders were not carried out, nor indeed intended to be, if only the persons concerned would conduct themselves properly and, as a matter of fact, pudding appears to have found its way to them. The action of the doctor was unauthorised by any express rule, but since by-law No. 2, section 26, apparently gives the House Surgeon the power of summary dismissal m cases of insubordination, it would seem that the minor alternative adopted could scarcely be regarded as a serious grievance. It is true that this could not be considered as an alternative in the case of the patient sent from the prison, but it is difficult to see what better means could be adopted of keeping him in order. 9.' " Is it true that many complaints are made as to the cooking of the patients' food ?" 10. " Is it true that the only time nurses get beef is when it is served up after having first done duty at the doctor's table ?" This in one of the other papers, Nos. 15 and 16, has the further allegation that " the steward has failed to exercise proper supervision over the food-supply of the Hospital." In the remaining one it stands as Nos. 6 and 7, which contain the substance of Nos. 9 and 10 above quoted from "Tongariro." , ...... Upon this subject of bad food, or bad cooking, or both, a great deal of evidence has been given, the general sum and substance of which may be shortly stated. The food and cooking are said by some to be satisfactory, and even excellent, whilst by a larger number much complaint has been made of both food and cooking, the quality of which during some years past is called in question. It is said that the fish has been frequently bad, that the meat has been ill-cooked, the puddings and soup containing more water than anything else, that the supply of eggs and vegetables was too scanty, and that at one time no beef appeared for weeks. In thus summarising the complaints Ido not distinguish between those that affect the nurses' or the patients' tables respectively. It is enough for me to say that, after making all allowance for the propensity of human nature to grumble at its food—particularly when this is supplied gratuitously—it seems pretty clear that the food department has not yet become quite what it ought to be. The complaints of bad fish appear to have been remedied by changing the contractor, and the watery character of some dishes is explained by leakage into them from the steam-pipes, a circumstance more satisfactory to the inquirer than to the consumer. Other defects in the kitchen apparatus account for occasional bad cooking. The supply and consumption of eggs have been shown to be very large, and when chicken could not be obtained rabbit has been got to supply its place, which, however, has unfortunately been regarded as a grievance by some of those concerned. The occasional defect of beef has not been quite explained but with regard to the complaint that when the nurses got any it came from the doctor's table it appears that his own partiality for that dish in a cold condition would prevent any extreme abuse in that direction. With regard to the food question generally, it seems to have been felt that not much could be done in the way of reform until the new Nurses' Home should be finished. Whether that be a sufficient excuse or not for all the shortcomings 1 can hardly say, but it does appear that whilst complaints to the Board and to the present matron, as well as her predecessor, were always attended to, and were followed by some alleviation of what was wrong, yet no permanent effect was produced. But now that the Nurses' Home is m workmg-order the matter is bein" taken in hand, and the Board is about to institute a thorough scheme of renovation and improvement in the kitchen and cooking appliances. It is alleged that the steward has not exercised proper supervision over the food-supply of the Hospital. It seems to be true that he has practically limited his duties under by-law No. 2 to the inspection of dry goods and groceries, although sections 50 and 51 point to the extension of these duties to all classes of provisions. He might, by a strict compliance with section 46, have sometimes prevented questionable fish from coming in, but the faults in cooking would have remained. It is to be hoped that the improvements to be now introduced will have the effect of removing all reasonable grounds of complaint about the quality and preparation of the food. _ In connection with this subject, it seems appropriate to notice the objectionable arrangement of the hours for meals which now exists. The tea-hour is far to early for persons not in robust health, when no further refreshment is obtainable until breakfast time the next morning. It ought to be enough to mention this to secure attention to the point and some alteration of the practice. _ 11. " Is it true that the House Doctor formulated a charge against the nurses, and laid it in

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all seriousness before the house committee, the said charge accusing them of a grave and serious breach of discipline in having presented Dr. Stewart with a testimonial of their respect without having first obtained his (the House Doctor s) permission ? " This is repeated in one of the other papers under No. 6. The answer is that it is not true. No objection was ever made to the presentation to Dr. Stewart, but to the use of the Board-room by the nurses without leave asked. The House Surgeon mentioned this verbally to the Chairman, at whose request he made a written report to the house committee. That body pronounced the act to be a breach of discipline, but, under the circumstances, one to be passed over lightly. It is probable that most of the nurses did not know that any formality had been neglected. 12. " Is it true that the House Doctor is in the habit of operating on patients without the permission or knowledge of the visiting staff? " 13. "Is it true that important operations are done without the whole staff being duly notified? " This is No. 7 in one of the other papers, and No. 8 in the other. To the first of these questions, the answer is that it is not true that the House Doctor is in the habit of operating without the consent, either express or implied, of the member of the visiting staff who has charge of the case. In reply to the latter of the two questions, it is to be said that some laxity has crept in with regard to the notification of operations to the staff; but this has arisen from the laxity in attendance of the members of the staff themselves, and notably so of Dr. Stewart. But notices have been posted up where they could be seen by the visiting physicians and surgeons on their ordinary visits. It might have been thought that a complaint of this sort could have been safely left to the staff to deal with, as they can scarcely be so helpless as to be unable to remonstrate should they feel in any way aggrieved. 14. " Is it true that the House • Doctor goes outside to administer ether or chloroform, such being a breach of the rule of the institution?" In one of the other papers this stands as 9, and states that " The House Surgeon administers chloroform to private patients of other medical men outside the Hospital." . It is true that the House Surgeon does this; but it is not so clear that it is against the rules. By-law No. 2, section 35, says, "The House Surgeon shall not practise out of the house." The question whether the administration of anaesthetics, at the request of other medical men, and to their patients, should be considered as "practising" was brought before the Medical Society by Dr. Murray-Aynsley himself, and the question, considered as one of medical ethics, was determined in the negative. It seems that Dr. Murray-Aynsley is regarded as specially expert in the doctrine and practice of anaesthetics, and, if medical practitioners outside the Hospital desire his assistance. I do not see why he should be debarred from rendering it, so long as neither the Medical Society, from its point of view, nor the Hospital Board, from the one proper to itself, makes any objection. The latter body can, of course, at any time put a stop to the practice, if it should become desirable to do so. 15. "Is it true that the House Doctor, on his rounds through the wards, frequently smokes cigarettes, greatly to the annoyance of the patients?" This is No. 8 in another paper. The answer is that it is not true. 16. " Is it true that a poor dying girl, full of sores, after a long wearisome journey by rail, was brutally turned away from the Hospital-doors at 9 o'clock at night, to find a bed elsewhere ? " This is No. 10 in one of the other papers. The incident here referred to happened on the 4th June, 1894. On that day the patient, Ellen Kennelly, was brought down from Hawarden by her relative, John O'Carroll, and taken to the Hospital in a cab at about 8 o'clock p.m. On the way to town Mr. O'Carroll sent a telephonic message from Sefton to notify to the House Surgeon that a patient was coming, but, as he had to continue his journey by the train, he could not receive a reply. A reply was, however, sent by the House Surgeon to say that there was no room for the patient. On arrival at the Hospital the House Surgeon objected to take the patient in, and an altercation followed between him and Mr. O'Carroll. This was ended by the doctor ringing up a nursing-home (Eowen's) to inquire if the patient could be admitted there, and on receiving an affirmative reply she was taken there. Whilst the discussion was going on the patient remained in the cab, and was not in any way examined by the doctor. The following day, through the mediation of Mr. Gray, a member of the Hospital Board, the patient was admitted to the Hospital, where she died the same day. The accounts given by Mr. O'Carroll and Dr. Murray-Aynsley respectively of what passed between them on the evening of the 4th, as might be expected, do not quite harmonize. The former says that he pressed the doctor to examine the patient, but unsuccessfully. The doctor, on the other hand, says that he gathered from the conversation that the illness was not of long duration, or very serious, and that he was encouraged in this motion by the circumstance that O'Carroll insisted not so much on the urgency of the case as upon the fact that he was able to pay for her accommodation in the Hospital. The doctor thought that in that case she might as well be at a nursing-home. In Mr. O'Carroll's evidence there are certainly signs of animus. He appeared to be reluctant even to admit that it was the doctor who directed them to the nursing-home, and his suggestion that the doctor was not sober, with his reasons for it, look very like an afterthought. O'Carroll says he never got out of the cab, and that if the doctor had been sober he would have known it. But in that case the cabman, John Howard, must have been intoxicated also, for he believes that O'Carroll did get out of the cab. The suggestion of drunkenness, in my opinion, is quite unworthy of credit. Nevertheless, the cabman confirms O'Carroll's statement that he did ask the doctor several times to look at the patient, and that the doctor's manner was rough and angry. I think that, after making every allowance for the scarcity of beds, and for the circumstance that the doctor, before sending the patient away, assured himself that she could be taken to a suitable institution, it yet cannot be denied that in this instance he committed a grave error of judgment. If this precaution had not

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been taken the incident might perhaps have justified the expression of " Tongariro " that the girl " was brutally turned away " ; but the use of such phraseology, whilst omitting all mention of the nursing-home, is in keeping with the partisan and disingenuous spirit which pervades his letter. There is no reason to think that the patient's life could have been prolonged in any case, since she was in the last stage of tuberculosis, but it is a deplorable thing that in her condition any difficulty whatever should have been placed in the way of her prompt admission. It is right to add that the House Surgeon candidly admits that he made a mistake on this occasion, and that had he examined the patient he would have found room for her. 17. "Is it true that a |man who had a sudden stroke of paralysis was refused admission into the Hospital on the ground'that the Hospital was not a proper place for such cases ?" This appears as No. 11 in one of the other papers, and, in the third, the name of the patient is mentioned in a list of those in respect of whom the House Surgeon is charged with "cruelty, indifference, and neglect." It stands as No. 11. This is the case of Albert Burt, particulars of which are given in the evidence of J. A. Frostick, of Dr. Murray-Aynsley, and of Dr. Mickle. The patient had an attack of paralysis, and the House Surgeon desired to have the opinion of a legally-qualified and responsible medical practitioner before sanctioning his admission to the Hospital." Although Mr. Frostick felt irritated at what he considered unnecessary delay, yet the event showed that the House Surgeon had rightly judged that such cases should not be moved without medical advice. Dr. Stewart, who saw the patient, says it was unquestionably a case for admission, but Dr. Mickle, who was called in, did not think it then safe to remove him; but in.the course of a few days, his condition then admitting of it, he was taken in, and did well. 18. " Is it true that a man (an accident) was turned away recently from the Hospital, the House Doctor telling him there was nothing the matter with him, while he is at present under treatment for a fractured leg?" This is No. 12 in one of the other papers, and in the third it is referred to in No. 11 before mentioned. This is the case of Eobert Green. The facts, as shown by his own evidence and that of his medical .attendant, Dr. Irving, are, that he was admitted for an injury arising from a blow upon the upper part of the shin-bone. There was no fracture at that place, and attention was not drawn to any other part. The patient did not wish to go to the Hospital, and did not wish to stay there, being desirous to go home and be attended by his own doctor. Accordingly he went out, after being in the Hospital about eight days. Afterwards he appears to have made the discovery for himself that the bone was movable at a point lower down, and Dr. Irving, on examination, found a fracture at the spot pointed out. Dr. Irving describes it as a " crack," which caused no displacement, and might quite easily be overlooked. I may add that I have myself heard one of the most eminent surgeons in London say, many years ago, that he had never seen a case of fracture of the tibia without the fibula, or small bone of the leg, being broken too. So that the case must be looked upon as remarkable and unusual, and the omission to notice the fracture a thing that might happen to any surgeon. Moreover, no harm came of the oversight, and the patient himself does not appear to have made it a cause of complaint. One would scarcely have expected to find one surgeon bringing up a case like this to damage the reputation of another. This completes the statement of charges—or, rather, of questions implying them—in " Tongariro's " letter; but it will be convenient, as before said, to deal in the present connection with the remainder of those set out in the other two papers. The list of cases in which cruelty, indifference, and neglect are alleged, comprises, besides the cases already considered, other names which I shall now take in order : — Mrs. Blliston : The substance of this patient's complaints is that Dr. Murray-Aynsley, having, when acting in Dr. Murdoch's absence for the Charitable Aid Board, sent her into the Hospital for feeding-up and special treatment preparatory to an operation, she got neither the feeding-up nor the special treatment. Dr. Murray-Aynsley confirms the statement that she came in for the purpose of being fed up for an operation, but he did not think that the use of the syringe, which was the special treatment she looked for, was necessary in her case. In respect of the diet, I think that she probably had some cause for complaint. I have already referred to the meal-hours, and I can only repeat that it is idle to bring patients into a hospital to be "fed-up," and then to give them nothing between a meal of tea and bread and butter at 4.30 p.m. and a breakfast of porridge and bread and butter at 7.30 the next morning. It seems right, also, that a little special attention should be given to cases in which, from some cause or other, the usual meal cannot be relished, and the patient should not be allowed to go without anything until the next meal. But it is difficult to see why a special accusation is made against the House Surgeon in this particular case. The patient says that she never complained to him all the time she was there, and he may naturally have thought she had nothing to complain of. As to the medical treatment, if the staff surgeon whose name was on her card never, as she says, saw her, that is his responsibility. The House Surgeon, not deeming any special treatment required, may have seen no necessity to send for the surgeon in charge of the case, and no special request appears ever to have been made to him on the subject. It may be added that Mrs. Blliston seems to be a person not likely to minimise any grievance, and on a subsequent occasion, when the matron came to her house with Dr. Murdoch to inquire what she had been complaining of, Mrs. Elliston became somewhat abusive, so that the doctor thought it best to shorten the interview. Mrs. Pankhurst: This case need not detain us long. The ground of complaint is chiefly that the patient was sent out of the Hospital before she was fit to go. There is nothing to show that this was the case. The doctor considered her fit to go, and, her bed being wanted, he may not have felt desirous to keep her in longer than was necessary after finding out from other sources that she had told him a falsehood, as she herself admits, in saying that she had no home to go to. This patient's complaints of the food may be well founded, but this comes under a different head.

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George Tibbs : Any one who will read this man's evidence will, perhaps, find it as difficult as I do to explain why he was called to substantiate charges-of cruelty, indifference, and neglect against the House Surgeon. So far as he is personally concerned, his evidence tells all the other way. The ncident of the fever-ward merely requires the explanation that there was no danger of infection from entering it, as some of the patients seem to have supposed. Tibbs gives some evidence about Lennie's removal; but this case will be noticed in its turn. P. J. Montague : This man stated in his evidence that he was five or six days in the Hospital; but the evidence of the House Surgeon, supported by the Hospital records, shows that he was admitted on the 11th of March, and went away of his own accord on the morning of the 13th. This does not prepare us to place implicit confidence in the accuracy of his statements. He had been hurt by a fall from a horse, and came into the Hospital suffering from pains in the stomach and an injury to the shoulder. He was put on milk diet, and, being dissatisfied with this, he went out. His shoulder was either not attended to, or was rubbed with liniment. He says his shoulder was out, and still remained so, but no evidence was called to prove this. I made an examination of his arm myself, and found no reason to think it had been dislocated, but it had been severely bruised, and the muscles were wasted and comparatively powerless. This man was first examined by Mr. Brown, the chief wardsman, who appears not to have discovered the injury to the shoulder. The House Surgeon states that the amount of his work makes it necessary for him to trust very much to the examination made by Brown of any patient who comes in when he is absent, and it must be remembered that Brown does practically fill the place of an assistant-surgeon. The system is, I think, by no means to be approved, but so it is. I am rather incredulous about Montague having called the special attention of either Brown or the doctor to his shoulder; but, if he had done so, it does not seem that any very special treatment was required beyond rest, if the theory of dislocation be rejected, as I think it must. If he had remained in the Hospital there can be no doubt that this injury would very soon have been observed; but his voluntary departure, after being only one clear day in the Hospital, takes away the ground of his complaint. It may be here°noted that Mrs. Neill says that an injury of this sort could not have failed to be discovered by a nurse trained in modern methods, and properly applying them. Edward Strange: This case will be found in the evidence of Mrs. Henrietta Grimsey, the lad's mother. I hardly know what the House Surgeon has to answer in this matter, unless it be that he sat on the table and protested against people giving trouble by coming on the wrong days. It was also implied that some neglect was shown in failing to put a protective plate on the boy's head for three months after the operation of trephining. But no medical evidence has been called to show that anything wrong was done or anything right omitted. The case proves no neglect on the part of the doctor, but very great pains on the part of his accusers in bringing forward everything that offered any prospect cf making good some imputation against him. James Lennie : Already referred to as mentioned in the evidence of George Tibbs. The complaint is that this man, who was partly paralytic, was dragged out of the Hospital with violence, and afterwards left outside his own door, where there was no one to receive him. The facts are that he was directed to be sent out by Dr. Deamer, and that when the time came he would not go, and force had to be used to get him into the cab. I think it is apparent, from his own evidence, that no very great violence was used in getting him to the cab, and that other accounts have been rather exaggerated. He was taken to the Charitable Aid Board office, and thence to his own home, Whitelaw, a porter of the Hospital, going with him. What occurred after leaving the Hospital must be gathered by comparing Lennie's own evidence with that of Whitelaw. But the House Surgeon is only concerned with the former part of the business, and, although it is impossible to say whether milder measures might have been successful in inducing the patient to accept the necessity of going out, I do not think it has been shown that the doctor did anything wrong. Mr. Eye : The complaint in this case is that the patient was sent out of the Hospital prematurely, and that he died a week after going home. This patient had cardiac and renal disease. A week before he finally left the Hospital he had gone home on a visit, and returned again. When he finally went out it was at his own wish. His disease might end in cardiac effusion at any time. He was quite comfortable in the Hospital, and there was no complaint of his treatment. I find no ground for this charge. Eobertson : There is nothing to say in this case, as no evidence has been tendered. James Pearson : I mention this and the following case here because they belong properly to this connection, and evidence has been led upon them, although they have no place in the list of charges. This man was treated for a broken leg, and it was not discovered until three weeks after he came in that there was also a fracture of the thigh. This certainly ought, according to the recognised rules for the examination of surgical cases, to have been found out at first. But this case presents the remarkable feature that the patient himself never felt or complained of any injury to the thigh. This, although not entirely excusing, readily accounts for the mistake in which Dr. Stewart avows himself to be a participator with the House Surgeon. Miss Graham : This patient is alleged to have been sent, or, rather, allowed to go, out of the Hospital when seriously ill. The particulars are given in • the evidence of Margaret Graham, Anne Walker, Dr. Gosset, Nurse Ewart, and Dr. Murray-Aynsley. The patient went direct from the Hospital to Mrs. Walker's house, stayed there one clear day, and on the next went on by rail to Southbridge. There she was to ill to go on to her home, but she went there a fortnight after, and she died in about three months. There seems no doubt that she was very unwell when she got to Mrs. Walker's, but she had walked there from the tram, a distance of about half a mile. She had been in the Hospital for an operation on the eye, from the effects of which she had recovered, and the House Surgeon says was becoming " hospitalised," and was in a fit state to be discharged. She went out by her own desire, being anxious to get home. Dr. Gosset, who saw her the morning after her arrival at Southbridge, was surprised at her having been allowed to leave the Hospital the day before —that is, the Ist November—not being aware that she had left on the 30th October. He

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says that the attack from which he found her suffering was so acute that it must have been of very recent origin, and the question is therefore whether she must have been at the time of her leaving the Hospital in such a state that ordinary care and observation on the part of the doctor or nurse could not fail to reveal the fact that a serious attack of illness was even then coming on. I cannot say that the evidence on the whole convinces me that this must have been the case, although, had she been discharged without or against her own concurrence and desire, I should have thought it culpable negligence to omit a careful examination. But it would be going too far to apply the same rule to a patient who is anxious to leave, and who, moreover, was convalescent from the particular complaint for which she had been under treatment. However much, therefore, this unfortunate case is to be lamented, I do not think it would be just to pronounce the House Surgeon guilty of a clear neglect of his duty. This completes the charges of cruelty, indifference, and neglect against the House Surgeon, and we may proceed to other allegations. 9. " That the House Surgeon issued an order to ' squirt' water in children's faces." He issued no such order, but on one occasion he himself performed this formidable operation, with the result that the child was temporarily cured of a violent fit of screaming, and the nurses, we may hope, learned something of the character of reflex action caused by a sudden impression on the fifth pair of nerves. I have not heard that any one was much the worse for the performance. 10. " That the House Surgeon has been under the influence of liquor and drunk while in charge of the Hospital." The only instance in which the House Surgeon is charged with being so far under the influence of liquor as to incapacitatate him for the proper discharge of his duties is that in which Francis O'Neill describes how the doctor came at night to see a patient named Bowley, and how he staggered and fell over the man's chest. Now, the fact is that this patient, Bowley, had that evening had his foot amputated, that under chloroform his respiration had failed, and that artificial respiration had to be resorted to. This again happened when the patient was brought into the ward, and the same process had to be repeated. The operation of artificial respiration was, I suppose, what O'Neill considered to be tumbling over the man's chest. At all events, the evidence of Dr. Meares, who was present in the ward for two hours, ought to be conclusive, and he says that the House Surgeon was perfectly sober. But the other evidence of a witness who sees so imperfectly, and so misinterprets what he sees, must be taken with very large allowances when uncorroborated. There are two or three other witnesses who speak of the doctor's manner as having been on some occasions "funny," " excited," &c, which they attribute to the influence of liquor. On the other hand, there is an overwhelming preponderance of witnesses who testify to the habitual sobriety of the doctor. And this is not merely negative evidence, for a large number of these witnesses, from their opportunities of judging, must have known if the doctor had been addicted to liquor. Without attempting the tedious task of analysing the evidence, I shall be content with saying that I think the charge of being under the influence of liquor is not proved, and the charge of being drunk is disproved. 12. " That the matron has been guilty of cruelty in dealing with applicants for admission." (This is No. 17 in the other paper.) It seems that whilst some repairs were going on at the Hospital the pathway to the back-entrance, by which patients are usually brought in, was littered with bricks and rubbish. On one occasion, a patient being brought to the front, the matron told the bearers to go the other way, and they went accordingly. On another occasion, when a remonstrance was made, the matron at once consented to their coming in by the front way. There is no reason to doubt that if the state of the path had been brought to the matron's notice the first time she would have allowed the front-entrance to be used whilst the obstacles remained, although the other is the best and most suitable entrance for patients who are carried in. 13. "That the matron has constantly administered ether and chloroform, the House Surgeon only being in attendance." Read "frequently" for " constantly," and the statement is quite true, and the practice justifiable. It seems to be forgotten that a school of trained and skilled nurses has sprung up within the last few years, and that tuition in the administration or anEestheties forms a part of their training. 14. "That the matron has been inattentive and neglectful of duty, particularly as to visiting wards at night." My conclusion from the evidence generally is that this charge is not true. 17. " That, while the patients have been stinted of food, there has been otherwise waste and extravagance of the food-supplies." Ido not know what specific circumstances this refers to, but of course bad food and bad cooking imply waste, and that both of these causes have sometimes afforded just grounds of complaint must be admitted. 18. " That there is no proper system of checking the administration of the steward as to (a) the consumption of medical comforts, (b) the amounts due by and received from patients, (c) the effects of patients." 19. " That no control is exercised over the Destitute Patients' Fund." (These are No. 15 in the other paper.) The discussion on these 'subjects has to a great extent resolved itself into the question whether it is right that the duties of secretary and treasurer should be conjoined, as they now are. Theoretically considered, it is perhaps desirable that they should be separated, but to do this would present difficulties in practice, chiefly on the ground of expense. I think that, with regard to the matters mentioned, there is not an adequate system of checking and controlling the administration and the accounts of the steward, but no abuse in practice has been alleged, except the specific one which I shall next mention, and which stands in one of the papers of charges as No. 16. 16. " Part only of charges made in many cases for burials from the Hospital was paid to the undertaker; the remainder was retained by the secretary." This allegation means that the contractor for the Hospital funerals, for which the deceased's friends are not able to pay, takes them at so low a rate as to incur a considerable loss on every one: that by way of compensation he engages the interest of the secretary to procure for him the funerals of those who can pay, and

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that he secures this interest by giving the secretary a commission out of the charge made to the friends for the funeral. The statements relating to this will be found in the evidence of Henry Scrimshaw, who says that when he was contractor he frequently paid the secretary a commission varying from £1 10s. to £2 10s., naming on these occasions to the secretary the price at which he was willing to complete the funeral, and leaving the secretary to fill in the account to the friends with a larger sum, he (the secretary) retaining the difference. This is a charge to which most persons would be inclined to lend a ready ear, when informed that the "pauper funerals" were done by this particular contractor at 7s. 6d. a head, and that they are now actually reduced to 2s. for adults and Is. 9d. for infants. But the truth of a statement is not to be accepted because it is plausible, and in the present instance we have simply the sworn assertion of one man against the sworn denial of another. The charge is that the secretary has accepted bribes to put business in the way of his accuser, and the latter is the man who, according to his own account, gave the bribes. His assertion is unsupported by other evidence. To support his statement he endeavoured to identify particular cases by latter additions to the entries in his books, and in cross-examination he was shown to have made specific statements which, as regards the cases to which they referred, were absolutely untrue. I must therefore conclude that this man's evidence is unworthy of credence, and that the allegation made is without proof. But I think it right to call attention to this extraordinary system of contracts for the funerals of the poor. It seems to me an unsatisfactory answer to say that in fact these funerals are decently conducted. I submit that the practice of giving contracts for work at a merely nominal price is a vicious system, and only too likely to lead to abuse of some kind. It is clear that if the " pauper funerals " were let at a price that would yield the contractor some profit, however moderate, the friends of deceased persons who are not paupers might have a chance of getting the funerals for which they pay at a more moderate price than at present —a consideration of much importance to many of them. 13. " Several old nurses who had been in the institution for many years, and had proved themselves good and faithful servants, were a short time ago dismissed without cause, and were only taken on again after public indignation had been expressed on the subject. " 14. " Nurse Cameron, who had been a night-nurse in the accident ward for six years, was dismissed on charges of immorality and cruelty without giving her an opportunity of hearing the evidence against her or of defending herself, although she went to the meeting of the Board with twenty witnesses in her behalf." This stands as No. 20 in the other paper, thus : " That the authorities in charge have retained persons on the staff unfit for their duties, while seeking to dismiss highly-qualified and experienced nurses." It will be convenient first to deal with the statements about Nurse Cameron. This nurse does not appear to have been charged with immorality, as alleged, but with undue familiarity with a patient named Stewart, and in that connection with breaches of some of the by-laws. Of this Mrs. Neill, after her inquiry, considered that there was sufficient evidence, and she also came to the conclusion that, although there was no intentional cruelty, yet that the nurse's manner to patients had been so rough and ungentle as to merit the name of cruelty to sick and helpless persons. But it is not true that Nurse Cameron was condemned or dismissed without a hearing, or an opportunity of defending herself. In the first place she was suspended, as a result of inquiries made by the House Surgeon into certain charges made against her. When her suspension was notified to her she was furnished with a list of the charges made against her, and the 30th January was appointed for an inquiry into these charges by the house committee. This inquiry was, however, deferred in consequence of a proposal that a general inquiry into the matters alleged in the " Tongariro " letter should be made by Dr. MacGregor, in which inquiry it was thought that Nurse Cameron's affair might also be included. The general and particular inquiries were subsequently made by Mrs. Neill. Mrs. Neill had an interview with Nurse Cameron, in which she obtained from her a general reply to the charges, and a further interview was appointed for the 16th February, which, however, Nurse Cameron failed to keep. The impression that Nurse Cameron was not granted a hearing may have been partly caused by the circumstance that when Mr. Knight Hunt, her solicitor, on the 13th February, applied to Mrs. Neill for a copy of the evidence against her, he received in reply a letter, the purport of which seems to be that Mrs. >Neill declined to recognise any solicitor in the matter. That in so declining she acted with perfect propriety Ido not see how there can be the least doubt. A lady, contemplating the dismissal of a housemaid, would hardly feel called upon to furnish the latter's solicitor with a written copy of the evidence against her; and I entirely fail to see why any different procedure is to be adopted in the case of a hospital nurse, notwithstanding the greater dignity and importance of her office, which I would certainly be the last to underrate. Any servant whatever, if wrongly dismissed, has a remedy at law, but in the meantime the matter lies solely between himself and his employer. Perhaps it would have been better if Mrs. Neill had explicitly stated in her letter to Mr. Knight Hunt that she would still expect to see Nurse Cameron at the appointed time and place; but it was in no way necessary for her to do this, and, if it was by her solicitor's advice that the nurse absented herself, I can only say that such advice, however suitable for'the purpose of fomenting an outside agitation, was little calculated to clear her in the of her employers. But this is not the only occasion on which Nurse Cameron has failed to avail herself of the opportunities offered her. Throughout the whole of my inquiry she has never come forward either to refute any of the charges made against her, or to establish any complaint of unjust treatment of herself by the Hospital authorities. She has, however, married the very man with whom she was accused of too much intimacy. The whole of the allegations about Nurse Cameron may be considered to have fallen entirely to the ground. But the fact that this supposed grievance in the case of Nurse Cameron has so completely failed to be substantiated surely affords some general presumption that, with regard to other nurses also, the Hospital authorities would be likely to judge more accurately of their conduct, their capacity, and their fitness for different kinds of duties than irresponsible persons outside. This is

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only a presumption, but it is an eminently reasonable one, and requires to be met by specific proof, and not by empty declaration. It is to be noticed that, while one of the papers of charges alleges that the nurses in question were dismissed and only taken on again in consequence of public indignation, the framers of the other, knowing that no nurses except Nurse Cameron had been dismissed at all, assert only that it was sought to dismiss them, leaving it, I presume, to be implied that this would have been done but for the public indignation referred to in the other paper. But it has been shown that no intention to dismiss, without finding some other provision for the persons concerned, has been entertained. This question of getting rid of the older nurses really resolves itself into two heads, one of which relates to their capacity and efficiency, and the other to their alleged misconduct in forming or associating themselves into some sort of faction or cabal to thwart improvements and reforms in the organization of the nursing staff. The former branch of the subject needs no elaborate argument, and, indeed, it is really difficult to see what there is to discuss about it. The simple fact is that a new and greatly improved system of nursing has sprung up of late years, and is fast superseding the old system, which had grown up in times when it was not generally understood that nursing is a scientific art, and in a time when popular education had not become generally diffused, and the people had not learned to demand everything of the best quality in their public institutions. That in such a state of things there should be friction between the declining and the rising systems is, of course, inevitable, and that the former should manifest its inferiority when exhibited alongside of its newer rival is only in the nature of things. When, therefore, we are told by experts that what might have been expected by those who are not experts has actually happened when the matron and the House Surgeon say that the nurses who have inherited the older traditions only are inefficient when tested by the standard of modern requirements, and when this is confirmed by the Inspector-General, and by a lady so eminently qualified to judge as Mrs. Neill, it is reasonable to ask what there is to set against a case thus recommended by its own intrinsic probability, and proved by the evidence of responsible experts whose business it is to judge and to act ? The answer is that there is nothing to be said; and, accordingly, the opposition to the reforms takes the shape of appeals to compassion and assertions of the hardship to old and faithful servants who are to be displaced to make room for younger rivals. The benevolent people who use this argument must command the sympathy of right-thinking minds, and certainly the contemplated reform should not be effected in a harsh or hasty manner. On the contrary, the greatest consideration should be shown to these old servants, even at the cost of some present inconvenience and some delay in completing the necessary reforms. But what ought to be distinctly understood is that the reforms are necessary, and that they must take effect; that the delay is in itself an evil, and that it is only tolerable in connection with the real and practical intention to take the earliest opportunity that may offer of providing otherwise for those who, through no culpability of their own, have become obstacles to the march of progress. In these remarks I have particularised no names, nor do I think it necessary to do so, because I believe the professional and responsible heads of the nursing staff to be the only authority competent to pronounce upon the degree of efficiency or inefficiency displayed by this or that nurse. No doubt those who are yet capable of learning and improving ought to have every chance ; but I cannot doubt that the principles which I have above indicated must command the assent of all who are unbiassed, and I think that a Board which should hesitate to co-operate with its skilled officers and responsible advisers in giving effect to those principles would show a strange misunderstanding of its duty, or a strange indifference to its performance. Thus much of the necessary conflict between an old system and a new ; but it is alleged that the older nurses have conspired to frustrate reforms, and have introduced insubordination, and caused confusion in the administration of Hospital affairs, or, to use the words of the InspectorGeneral, they have formed " a cabal which paralysed the authority of the Eesident Surgeon and the matron, and the result was to cause such internal friction as to make the position intolerable." If it was natural and inevitable that the introduction of a new system should seem a grievance to those whose interests were bound up with the old, it was also natural, though not justifiable, that the feelings of jealousy so excited should find some mode of expression. Accordingly, we find some of the old. school indulging in sneers at the expense of the new, talking about " broken-down ladies," &c. There can be no doubt that this has happened, nor that it happened often enough, to make some of the probationers unhappy and depressed in spirits, a condition the most unsatisfactory for the performance of the duties of a nurse. There is no evidence that this was caused by any conduct on the part of the probationers—that they gave themselves airs, or did anything to provoke such manifestations of feeling. On the other hand, it is fair to say that these manifestations do not seem to have occurred —at all events, to any serious extent —until the suspension of Nurse Cameron created alarm, excitement, and animosity. How far the nurses who felt their position endangered allowed their alarm to carry them into improper speech or action is not very easy to determine. The apprehension of a common peril would naturally, and without pre-deter-mined arrangement, bring them frequently together in conference and counsel; and, if any persons outside the Hospital encouraged confidences, or held out the hope of aid, it is obvious that what might deserve the name of a fiction or cabal would insensibly spring up without any preconcerted design. From Dr. MacGregor's evidence, I gather that this is much what he meant when he spoke of " a cabal " in the passage above quoted. J3ut I think his language was rather unguarded, for the report certainly seems to imply that the " cabal " was the work of "the older members of the staff," and was confined to them, "and certain others whom they have influenced." There is no evidence to show that their disaffection led them to directly thwart the work of the Hospital, or that they ever failed to discharge their duties in the wards to the best of their ability. Indeed, it is difficult to see how they could have acted otherwise in these respects without at once giving a handle against themselves. In speaking of a " cabal," 2—H. 18.

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therefore, the element of outside influence is not to be lost sight of, and when it is said or implied that the administration of affairs was thwarted by a " cabal," I think it is this influence that is chiefly concerned. Both the House Surgeon and matron confess themselves to have been at times deficient in moral courage in dealing with matters as they arose, and they seem to have been apprehensive of some influence likely to prove too strong for them. Ido not think it necessary, even if it were possible, to determine how far this or that nurse may have associated herself with or sought the aid of such extraneous influence, nor would any good object be gained thereby, unless I could definitely pronounce that this or that nurse deserved immediate dismissal. But the evidence on the whole does not lead me to this conclusion. All the circumstances of the case must be taken into account: the natural feeling which induces every one to accept any help that offers for the purpose of averting an impending misfortune, and the tradition of lax discipline which had come down to them from the times of an older and. now effete system. These things considered, I am inclined to think that nothing has been done by the nurses which might not be condoned upon a promise of future observance of loyalty and proper subordination. I mean by this that those who, as I have before said, are capable of learning and accommodating themselves to the new system should be allowed to consider their positions secure so long as they co-operate ex animo with the heads of their department. Those, on the other hand, who are not so capable would come under the principles already submitted. But this procedure can, I think, safely be adopted only upon certain well-defined and well-understood conditions. The chief of these is that the Board should give a loyal and unflinching support to the House Surgeon and the matron in enforcing discipline and subordination, and every servant of the Hospital should understand that talebearing outside the walls would be visited with summary dismissal. It should also be made clear that for a nurse to carry any grievance direct to the Board, instead of through the matron, would be considered an act of distinct insubordination. It would hardly be credited in some hospitals that the Board permitted a nurse, without rebuke, to bring before it a complaint that she had been removed from one ward into another. Unless different principles from these are acted on, Ido not see how the best-devised reforms can be expected to succeed. Before going on to consider what outside agency may have been at work to foment dissatisfaction or .cause trouble, it is convenient here to mention the case of Brown, the wardsman and dresser, whose services, both as one of the old school and as exercising an objectionable influence in the Hospital, it has been proposed to dispense with. This man occupies a peculiar position. He has been twenty-three years a servant of the Hospital, and in that time has necessarily acquired a great amount of experience and knowledge in respect of accidents, wounds, and surgical cases generally. There can be no doubt that he has been a very useful man by assisting at post mortem examinations, and at operations, by dealing with cases of accident which come to the Hospital during the absence of the House Surgeon, and by attending to such cases in the wards as require some little recurring operation to be performed while the patient's bed is screened off from the rest of the ward. Mr. Brown's services are so highly rated by some witnesses that they seem to think his place could not be satisfactorily filled, even by a qualified assistant medical officer, a view of the matter which seems to me rather difficult to support by adequate reasons. But Ido not see how his services can be altogether dispensed with without the appointment of a professional assistant to the House Surgeon. Mrs. Neill suggests the annual or semi-annual appointment of an advanced student from the medical school at Dunedin. This might do very well if such a student could be obtained; but this would present difficulty, as his time would not count in the course for getting his diploma. But most probably a young doctor just qualified could easily be obtained, as there are doubtless many who would be glad of the chance of getting twelve months' hospital practice, even without salary, before launching out on their own account. I strongly recommend this suggestion to the Hospital Board, even without any reference to Mr. Brown, since, whether he goes or stays, there is no doubt that the House Surgeon has much more work than he can properly or efficiently perform. With regard to Mr. Brown himself, he has been supposed to have fomented mischief within and agitation without the Hospital. Of this I have had no clear and direct evidence, which indeed would be very difficult to obtain in such a matter; but there is one point upon which an inference may fairly be drawn. Those who have arraigned the general management of the Hospital have put in the front place among their charges the statement about the probationers attending operations. Now, Mr. Brown is the only person in the Hospital who seems to have taken a strong objection to the system, and the part he has taken in making it difficult of working has been already mentioned. The origin of this complaint may therefore with much appearance of probability be traced to him. At all events, the attitude which he has assumed on this subject is plain enough, and the freedom which he has permitted to his tongue in connection with it hardly warrants implicit confidence in his discretion or his silence respecting any other subjects upon which he may happen to think or feel strongly. However this may be, there can be no doubt that this officer is out of harmony with the modern system, and that his continuance in his present anomalous position of undue prominence cannot fail to hinder the various parts of the machine from falling into their proper places and working with the facility which is essential. The coarseness which could impute indelicacy of mind to a young woman in the performance of her duty unfits him for any work which may require his presence amongst the nurses in the wards, and the license taken in assuming the right to speak as if he had the direction of things in the operatingtheatre shows to what undue dimensions the office of wardsman and dresser has been allowed to grow. This is the natural result of a system which has permitted that office to become practically the office of an assistant-surgeon; but the anomaly and inconvenience of such a system are now manifesting themselves, and the sooner some alteration is adopted the better for the Hospital. A perusal of the charges formally made, and which I have now at some length considered, will be enough to suggest as an irresistible inference that a great deal of communication must have been going on between persons inside the Hospital and others outside. It is not necessary, and

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would serve no good purpose, to go at length into the question how these charges were got up, and what particular share this or that person took in the matter. It is sufficient to say that, notwithstanding the deficiency of evidence, there is enough to show, independently of the " Tongariro " letter, that Dr. Stewart and Dr. De Eenzi were both concerned in the business. This is shown by such incidents as stopping a man in the street to ask him if he had ever seen the House Surgeon intoxicated, and ringing up another doctor to ask whether it was true that a patient of his just out of the Hospital had been discharged with a broken leg. It is for these gentlemen to consider how far they can reconcile their methods with any high code of ethics, either general or professional; and Dr. Stewart in particular might profitably reflect on the verdict which in the light of such a code must be pronounced upon his "Tongariro" letter, with its general spirit of disingenuousness and malignity, its reckless suggestion of what is false, and its aggravation or perversion of what is true by unfair phrases and turns of expression. Dr. Stewart, at the time of his writing this letter, was on the consulting staff of the Hospital, and had quite recently been on the active surgical staff. Yet, instead of availing himself of his position to get abuses rectified, he preferred to stir up the mud by an anonymous letter, making many imputations which were supported by no facts within his knowledge, and manifestly prompted by no unalloyed desire to promote the good working of the Hospital in the public interests. If the proportion in the letter of " Tongariro" between what is asserted, or implied under the equally effective form of questions, and what is proved by evidence in the sense so implied, be considered, it will remain matter for regret that one who could make such pertinent practical suggestions as Dr. Stewart has shown in his evidence that he was able to make should not have adopted a more reasonable mode of calling attention to abuses. With these remarks, this part of the subject may be left, and I now proceed to say a few words upon the outside agitation which, apparently started by the suspension of Nurse Cameron and the letter of "Tongariro," culminated in a public meeting, held on the 4th April last. Since it is evident that public agitation of this sort, whilst it arises from the real or supposed methods of Hospital management, must in its turn react upon that management, it appears relevant to notice it here with the view of ascertaining as far as possible whether public feeling and sympathy had been misled and caused to flow in wrong channels. The persons assembled at the meeting in question apprehended that the Board intended to make a clearance of many of its old servants, in pursuance of Dr. MacGregor's recommendation, and they judged of the motives of both the department and the Board by what they deemed to be an act of flagrant injustice already committed by the dismissal of Nurse Cameron, without giving her, as they supposed, an opportunity of defending herself. It would be difficult to-day to get up a meeting to protest on behalf of Nurse Cameron, and if the facts had been then known, it is easy to conceive that the speeches would have lost much of their point, and the public feeling much of its intensity. But the point of most interest and importance at the present moment is the feeling which was shown at the meeting in relation to the new system of nursing. I pass over the remark of one speaker, that "If the Hospital were to be turned into a nursing school, God help the poor people who had to go there," because the speaker must doubtless have afterwards reflected that, however true this might be of a school consisting of pupils only and no teachers, yet such a school had not been instituted or suggested. But I notice that Dr. MacGregor's remark, that " educated and refined young women " should be induced to take up nursing as a career, was received at one moment with hooting and at another with laughter. This is significant, not on account of the hooting and the laughter, which can be got by proper management from any crowd, but by reason of the apparent misapprehension which existed in the mind of the speaker who drew these manifestations of feeling from the ignorant and unthinking. For no one can suppose that this speaker, or any of the gentlemen who addressed the meeting, or any of the associations whose opinions we may suppose to have been reflected thereat, can entertain any dislike to " education and refinement," as such. Eepresentatives of progress, as all these persons and associations are, and agencies of " light and leading" in the work of rectifying human society, it is obvious that they can desire nothing so ardently as the general diffusion amongst all ranks of the " education and refinement " which have so long been unjustly restricted to the few. If, therefore, they have appeared for a moment antagonistic to the very thing the augmentation of which constitutes to so large an extent their own raison d'etre, it must be because they thought they were being offered shoddy instead of genuine stuff, and believed that their invective and their sarcasm were levelled at a wolf in sheep's clothing. They must have imagined—from whatever quarter they may have got the notion—that the phrase " education and refinement " was but a euphemism for "fine-ladyisin," and they plainly declared that they wanted none of it. These gentlemen and associations will therefore be gratified by the assurance that they are mistaken—that the modern system of nursing is not a dilettante business, or by any means suited to the young lady whose listless life craves for a new sensation. Such as she are soon weeded out by the sternness and exactness of modern training, and none are likely to be left except those who intend real and earnest work. When this is once understood we may expect that these leaders of public opinion in Christchurch will not only consent, but vehemently insist that the latest and best methods shall be introduced into their Hospital, however strongly they may desire to show the fullest consideration to old servants whose interests are imperilled by the remorseless progress of civilisation. It will doubtless come to be recognised by them that the department of hospital nursing supplies one mode by which the intelligence awakened and the mental alacrity cultivated by the school system so much valued by the public may be exercised in duties alike honourable to the workers and beneficial to the sick and suffering. I believe I have now gone through all the specific allegations which have been formally made against the Hospital administration. But other statements have been made in evidence in which either the general administration or the conduct of the House Surgeon or matron has been called in question. An instance or two will suffice. On one occasion a man died of sudden hemorrhage

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from the lungs whilst the wardsman who was in charge during the night was absent. He was called away by Night-nurse Cameron on account of an accident that had happened, and, of course, he ought not to have gone until his place was supplied. It is not suggested that anything could have been done for the patient, but such a thing ought not to have happened, and it could scarcely have happened if the new nursing system had been fairly established. A man who had cut his foot was sent out of the Hospital before the injury was quite well, and afterwards a minute piece of glass was expelled by an abscess. The case is comparatively trifling, and might easily happen when the state of the Hospital forbids a long stay in cases where this is not quite necessary. Dr. De Eenzi attended this patient after his discharge. A warder was seen to strike a delirious patient : the House Surgeon, upon inquiry, thought it might not have been an intentional blow, but a sudden movement of self-defence. I do not see what means now exist of reversing his decision. The House Surgeon and matron are alleged to have made an arbitrary rule that nurses and probationers should rise when either of these superior officers enters the ward. If this rule creates any surprise, it must surely be that it should be needed, for intuitive politeness and sense of what is becoming might be expected to dispense with the necessity for it. But it is laid down in English manuals of nursing instruction, and I do not think the objection to it proceeds from the younger nurses, but from some quarter where there is more ignorance and false pride than " education and refinement." The House Surgeon has been accused of discourtesy and roughness of manner by several witnesses, a complaint the weight of which it is difficult to estimate in consequence of the natural exaggeration usually indulged in by either party to a conversation partaking in any degree of the character of an altercation. Seasonable deductions must be made from such allegations, and Ido not think anything has been shown beyond a little occasional irritability or quickness of temper, and a propensity to plain speaking, with a defective appreciation of the advantages of conducting an argument suaviter in moclo. It is, of course, desirable that tact and patience should be cultivated as much as possible by an officer whose duties bring him so much into contact with all shades of human character, and perhaps in explaining the inevitably fatal result of delay in operating for a cancer it might be as well to refrain from telling a man " that he might as well get a rope and hang his stepmother as take her out of the Hospital." But why it was thought worth while to encumber the record's of the Commission with such matter as this is not easy to see, unless, indeed, it was seriously thought that the doctor was inciting to murder. There is one other matter upon which I myself called evidence, in consequence of what I found in Mrs. Neill's report about the case of a man named Berry, deceased, from which it appeared that a system of "terrorism" existed, or was asserted to exist, in No. 6 ward. The evidence of Thomas Brunsdon to some extent bears this out, and, at all events, goes to show that any high ideal of nursing-work was hardly to be found in that ward, and to justify the opinion of the heads of the staff as to the character of the older methods. The state of the Hospital during the years preceding the appointment of the present House Surgeon and matron is a subject upon which no very clear light has been thrown, in consequence of the fragmentary and incomplete character of such evidence as has been tendered in relation to it. Hints have been given of considerable irregularity and disorganization, but these have not been followed out or particularised in such a manner as to lead to any definite result. An instance of this may be given from Dr. MacGregor's evidence, who says that in the year 1889 Dr. De Eenzi made a statement to him which tended to implicate members of the Hospital Board in grave charges of irregular and improper conduct. The statement was of so serious a character as to cause Dr. MacGregor at once to see the Chairman and other members of the Board, and to point out to them the necessity of a thorough inquiry, and at the same time to call upon Dr. De Eenzi to reduce his statement to writing. The latter, however, after consideration and advice, declined to do so, and Dr. MacGregor says that, in consequence of this withdrawal from the accusations he had made, he himself has ever since disbelieved the statements, but that Dr. De Eenzi, having made and then failed to substantiate them, ought to have been immediately dismissed from his office. Few will dispute the correctness of this view upon the facts given, and it is difficult to understand how the Hospital Board could have refrained from insisting on one or the other alternative. But when Dr. De Eenzi is called, whilst admitting that he did make this statement to Dr. MacGregor, he qualifies it by saying that he mentioned it as a mere rumour, and adds the surprising assertion that he himself had no belief in its truth. Whether Dr. Eenzi expected this denial itself to be believed Ido not know, but there certainly seem to be difficulties in believing it. If these matters were only mentioned to Dr. MacGregor as mere rumours, why was this point not insisted on at the time in such a manner as to show him the futility of going to the members of the Board about it before the origin of the rumours was traced and the real accuser discovered ? Why was not Dr. MacGregor also informed that until those steps had been taken it would be useless for him (Dr. De Eenzi) to put anything in writing, instead of allowing the Inspector to go to Wellington, and then sending him a cautiously-worded letter declining for quite other reasons to do what had been asked? Again, if Dr. De Eenzi did not believe the rumours, why did he mention them to Dr. MacGregor at all, without at the same time taking some other steps ? Why did he not insist upon his informant within the Hospital substantiating his information, or accepting the only legitimate alternative? Dr. De Eenzi has certainly failed, in my opinion, satisfactorily to explain the part he took in this business, which is here mentioned, not with any reference to the truth or falsehood of the statements made, but because it seems to indicate some decided weakness in the management that such things could be said and no further notice be taken of the matter. Another question personally affecting Dr. De Eenzi incidentally came up during the inquiry, but, as I consider it irrelevant to the business I had to deal with, it seems unnecessary to say more about it here than that, so far as the facts transpired, Dr. De Eenzi's answer must be deemed sufficient.

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I believe that I have now discussed at some— but I trust not at undue—length all the prominent features in the matters brought before me for inquiry, omitting nothing of much importance m itself, or of which the consideration appeared likely to be fruitful. It only remains for me to place the conclusions at which I have arrived in a more succinct form, for facility of reference and of understanding. The House Surgeon : This officer has been shown to have committed on one occasion a somewhat serious error of judgment in sending away to a nursing-home a patient whose_ condition was such that she ought to have been at once admitted to the ward. In other eases which seemed on their face to suggest negligence or carelessness, the element of culpability appears wholly or nearly to vanish upon a careful consideration of all the circumstances. In one instance a temporary indiscretion was exhibited in the attempt to induce patients to attend the religious services in the wards by making their Sunday passes dependent on such attendance. All the other charges against the House Surgeon are, in my opinion, either false, or frivolous, or sufficiently answered by the plea of admission and justification. The appointment of an assistant resident medical officer is, in my opinion, one of the urgent needs of the Hospital. The Matron: Nothing has been proved against this lady, except her concurrence with the House Surgeon in the attempt—which was not persisted in—to make the Sunday passes of the patients depend on their attending the Church services. The matron may be somewhat deficient in the experience of housekeeping desirable in so large an establishment, but, whatever her experience, she ought to have assistance inthat department, since the nursing business, in which her efficiency is unquestioned, seems to be quite enough for the energies of one person. . . . . . The Secretary and Steward: No abuse of office has been, in my opinion, proved against this officer, but the system of letting contracts for the burial of the poor, with which his name has been connected, decidedly requires reconsideration and reform. , The union of the officers of steward with that of secretary and treasurer is, I think, objectionable, "the duties of steward being, in consequence, less strictly performed than they should be. But the appointment of a housekeeper may, perhaps, mitigate this difficulty. The advice of some skilled person should be obtained as to the best way of keeping the accounts of the secretary and treasurer, with proper checks upon them, and the scheme should include the Destitute Persons' Fund, now administerd by the Chairman of the Board. The Food and Cooking: This department has varied for a long time in respect of quality under both heads, showing frequent fluctuations between excellence and inferiority. The kitchen improvements now'to be carried out may remove all causes of complaint. The chief present desiderata appear to be the appointment of a housekeeper to look after this department; and an alteration m the meal-hours by which the interval between the evening-meal and the next morning's breakfast may be materially reduced. The former of these requirements might perhaps be met by the appointment of " house-sister," to be held by the ward sisters in rotation for three or six months at a time This plan has been proposed by Mrs. Neill, and is, I believe, supported by Miss Maude. Nursing: There is little further to be said under this head, except that the modern system requires to be steadily pursued, and. extended by degrees to all parts of the Hospital administration which have not yet been brought within its operation. _ _ This seems a fitting occasion to mention the great want that exists of some regular provision for nurses who have done good service in their time, but who, from age, infirmity, or other causes not attributable to any fault of their own, are becoming unfit for active service. Something might be done in this direction by a combination of public and private resources, and I have no doubt that there are many persons who would, if properly appealed to, by subscriptions, donations, or legacies, aid in establishing an adequate Nurses' Pension Fund. Some alteration appears to be wanted in respect of the mght-nursmg and the hours ot duty required in this department. Upon this subject the matron, with Mrs. Neill's advice, will, no doubt, be able to do all that is necessary. Wardsman and Dresser: The employment in what is virtually the office of assistant-surgeon ot a person who is neither a qualified medical man, nor pursuing the curriculum necessary for becoming one, is an expedient which might be justifiable in the early days of a hospital on a new goldfield; but'in any institution pretending to aim at even a moderate standard of modem completeness and efficiency it is an incongruity which should be no longer tolerated. And it has been shown in a former passage of this report how little likely is the present holder of this office to help or harmonize with an improved system of nursing. Chronic Cases and Infirmities of Age : Nothing is more urgently needed than some provision for cases of this sort outside the walls of the Hospital. The admission of such cases, which are not suited to a general hospital, is a cause of overcrowding and inconvenience ; and to it, doubtless, may be largely attributed the difficulty which sometimes occurs in the prompt admission of more suitable cases and the necessity of discharging others a little sooner than would otherwise be the case. The Hospital Board : I do not propose to say anything about the constitution of this body, except that I believe that if it were elected from a larger constituency there would be less opportunity given to local and personal influences in the management of the Hospital, and the Board would probably be able to" exhibit more courage and firmness in pursuing a straight course without fear or favour. But in whatever manner elected it is essential that the Board, if it thinks its head officers competent and trustworthy, should trust them in matters coming under their supervision. Nothing but very strong reasons should be allowed to weigh against a recommendation of the House Surgeon and the matron, and the hands of these responsible officials should be strengthened by all legitimate means in maintaining discipline and order. 3—H. 18.

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Medical Staff: lam glad to indorse the opinion expressed by several witnesses that the appointment of the staff for so short a period as one year is objectionable, and has no tendency to encourage the best and ablest practitioners to apply for an appointment. The representation of the medical staff on the Hospital Board, by giving a seat to the Chairman or one of its members, is a scheme which has elicited divergent opinions. I think it is likely to have some good effect, but the experience of other places has not proved it to be a specific for all troubles. Conclusion. —I now bring this report to a conclusion, with the hope that the somewhat tedious and minute inquiry in which I have been engaged, in pursuance of your Excellency's Commission, may result in some good by clearing up confusion, dissipating prejudices, refuting calumnies, pointing out the sources and proper remedies of complaints that are well grounded, and generally helping to facilitate the administration of the Hospital, to increase its usefulness, and to enhance the estimation in which it is held by the people of Christchurch. I have, &c, J. Giles. Approximate Cost of Paper. —Preparation, not given; printing (1,400 copies), £Q 3s.

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