ST. HELENS MATERNITY HOSPITAL, AUCKLAND (REPORT OF COMMISSION ON THE), TOGETHER WITH MINUTES OF PROCEEDINGS AND EVIDENCE.

Appendix to the Journals of the House of Representatives, 1913 Session I, H-31b

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1913 NEW ZEALAND.

ST. HELENS MATERNITY HOSPITAL, AUCKLAND (REPORT OF COMMISSION ON THE), TOGETHER WITH MINUTES OF PROCEEDINGS AND EVIDENCE.

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

COMMISSION. Robert Stout. Administrator of the Government. To all to whom these presents shall come, and to Charles Cargill Kettle, Esquire, Stipendiary Magistrate, Auckland : Greeting. Whereas allegations have been made regarding the administration of the St. Helens Hospital at Auckland, and it is expedient that inquiry should be made with respect thereto: Now, therefore, I, Robert Stout, Knight Commander of the Most Distinguished Order of Saint Michael and Saint George, the Administrator of the Government of the Dominion of New Zealand, in exercise of the powers conferred by the Commissions of Inquiry Act, 1908, and of all other powers and authorities enabling me in this behalf, and acting by and with the advice and consent of the Executive Council of the said Dominion, do hereby appoint you, the said Charles Cargill Kettle, to be a Commission to inquire and report as to — (1.) The circumstances surrounding the death at St. Helens Hospital, Auckland, of Laura Elizabeth Chamberlain; and (2.) Generally as to the administration of the said St. Helens Hospital. Arid for the purpose of your inquiry you are hereby authorized and empowered to call before you and examine on oath or otherwise as allowed by law all witnesses or other persons whom you think capable of affording you any information on the subject of this Commission, and also to have before you and examine all books, papers, documents, and writings you deem necessary- And you are hereby empowered and directed to conduct your inquiry at Auckland, in such manner and at such times and with such adjournments as you think fit. And, using all diligence, you are hereby required to report to me under your hand the result of your inquiry, with any recommendations you think fit to make in respect of the matters and things inquired into by you, under or by virtue of these presents, within one month from the date hereof. And it is hereby declared that these presents shall continue in force and virtue although the inquiry is not regularly continued from time to time by adjournment.

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And, lastly, it is hereby declared that these presents are issued under and subject to the provisions of the Commissions of Inquiry Act, 1908. Given under the hand of His Excellency the Honourable Sir Robert Stout, Knight' Commander of the Most Distinguished Order of Saint Michael and Saint George, Chief Justice, Administrator of the Government in and over His Majesty's Dominion of New Zealand and its Dependencies; and issued under the Seal of the said Dominion, at the Government House, at Wellington, this sixteenth day of December, in the year of our Lord one thousand nine hundred and twelve. R. Heaton Rhodes, Minister of Hospitals and Charitable Aid. Issued in Executive Council. J. F. Andrews, Clerk of the Executive Council.

r EXTENDING PERIOD WITHIN WHICH THE COMMISSIONER SHALL REPORT IN CONNECTION WITH THE ADMINISTRATION OF THE ST. HELENS HOSPITAL, AUCKLAND. Liverpool, Governor. To all whom these presents shall come, and to Charles Cargill Kettle, Esquire, S.M., of Auckland : Greeting. Whereas by a Commission bearing date the sixteenth day of December, one thousand nine hundred and twelve, you, the said Charles Cargill Kettle, were appointed to be a Commissioner, with the powers mentioned therein, for the purpose of making inquiry into matters affecting the administration of the St. Helens Hospital at Auckland : And whereas by the said Commission you were directed and required to transmit to me your report and recommendations in respect to the several matters inquired into not later than one month from the date thereof : And whereas it is expedient that the said period should be extended as hereinafter provided : Now, therefore, I, Arthur William de Brito Savile, Earl of Liverpool, the Governor of the Dominion of New Zealand, acting by and with the advice and consent of the Executive Council thereof, and in exercise and pursuance of every power and authority enabling me in this behalf, do hereby extend the period within which you shall (using all diligence) report to me, as by the said Commission provided, to the sixteenth day of February, one thousand nine hundred and thirteen : And with the like advice and consent, and in further pursuance of the said power and authority, I do hereby confirm the said Commission, except as altered by these presents. Given under the hand of His Excellency the Right Honourable Arthur William de Brito Savile, Earl of Liverpool, Knight Commander of the Most Distinguished Order of Saint Michael and Saint George, Companion of the Royal Victorian Order, Governor and Commander-in-Chief in and over His Majesty's Dominion of New Zealand and its Dependencies; and issued under the Seal of the Dominion, at the Government House, at Wellington, this thirteenth day of January, in the year of our Lord one thousand nine hundred and thirteen. A. L. Herdman, For Minister of Hospitals and Charitable Aid. Approved in Council. J. F. Andrews, Clerk of the Executive Council.

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EXTENDING PERIOD WITHIN WHICH THE COMMISSIONER SHALL REPORT IN CONNECTION WITH THE ADMINISTRATION OF THE ST. HELENS HOSPITAL, AUCKLAND. Liverpool, Governor. To all to whom these presents shall come, and to Charles Cargill Kettle, Esquire, S.M., of Auckland : Greeting. Whereas by a Commission bearing date the sixteenth day of December, one thousand nine hundred and twelve, you, the said Charles Cargill Kettle, were appointed to be a Commissioner, with the powers mentioned therein, for the purpose of making inquiry into matters affecting the administration of the St. Helens Hospital at Auckland : And whereas by the said Commission you were directed and required to transmit to me your report and recommendations in respect to the several matters inquired into not later than one month from the date thereof : And whereas the time within which you were required to report was extended to the sixteenth day of February, one thousand nine hundred and thirteen : And whereas it is expedient that the said period should be extended as hereinafter provided : Now, therefore, I, Arthur William de Brito Savile, Earl of Liverpool, the Governor of the Dominion of New Zealand, acting by and with the advice and consent of the Executive Council thereof, and in exercise and pursuance of every power and authority enabling me in this behalf, do hereby extend the period within which you shall (using all diligence) report to me, as by the said Commission provided, to the sixteenth day of March, one thousand nine hundred and thirteen. And with the like advice and consent, and in further pursuance of the said power and authority, I do hereby confirm the said Commission, except as altered by these presents. Given under the hand of His Excellency the Right Honourable Arthur William de Brito Savile, Earl of Liverpool, Knight Commander of the Most Distinguished Order of Saint Michael and Saint George, Companion of the Royal Victorian Order, Governor and Commander-in-Chief in and over His Majesty's Dominion of New Zealand and its Dependencies; and issued under the Seal of the said Dominion, at the Government House, at Wellington, this fifth day of February, in the year of our Lord one thousand nine hundred and thirteen. R. Heaton Rhodes, Minister of Hospitals and Charitable Aid. Approved in Council. J. F. Andrews, Clerk of the Executive Council.

EXTENDING PERIOD WITHIN WHICH THE COMMISSIONER SHALL REPORT IN CONNECTION WITH THE ADMINISTRATION OF THE ST. HELENS HOSPITAL, AUCKLAND. Liverpool, Governor. To all to whom these presents shall come, and to Charles Cargill Kettle, Esquire, S.M., of Auckland : Greeting. Whereas by a Commission bearing date the sixteenth day of December, one thousand nine hundred and twelve, you, the said Charles Cargill Kettle, were appointed to be a Commissioner, with the powers mentioned therein, for the purpose of making inquiry into matters affecting the administration of the St. Helens Hospital at Auckland : And whereas by the said Commission you were directed and required to transmit to me your report and recommendations in regard to the several matters inquired into not later than one month from the date thereof : And whereas the time within which you were required to report was extended first to the sixteenth day of February, one thousand nine hundred and thirteen, and again to the sixteenth day of March, one thousand

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nine hundred and thirteen: And whereas it is expedient that the said period should be extended as hereinafter provided : Now, therefore, I, Arthur William de Brito Savile, Earl of Liverpool, the Governor of the Dominion of New Zealand, acting by and with the advice and consent of the Executive Council thereof, and in exercise and pursuance of every power and authority enabling me in this behalf, do hereby extend the period within which you shall (using all diligence) report to me, as by the said Commission provided, to the thirty-first day of March, one thousand nine hundred and thirteen. And with the like advice and consent, and in further pursuance of the said power and authority, I do hereby confirm the said Commission except as altered by these presents. Given under the hand of His Excellency the Right Honourable Arthur William de Brito Savile, Earl of Liverpool, Knight Commander of the Most Distinguished Order of Saint Michael and Saint George, Companion of the Royal Victorian Order, Governor and Commander-in-Chief in and over His Majesty's Dominion of New Zealand and its Dependencies; and issued under the Seal of the said Dominion, at the Government House, at Wellington, this tenth day of March, in the year of our Lord one thousand nine hundred and thirteen. W. F. Massey, For Minister of Hospitals and Charitable Aid. Approved in Council. J. F. Andrews. Clerk of the Executive Council. EXTENDING PERIOD WITHIN WHICH THE COMMISSIONER SHALL REPORT IN CONNECTION WITH THE ADMINISTRATION OF THE ST. HELENS HOSPITAL, AUCKLAND. Liverpool, Governor. To all to whom these presents shall come, and to Charles Cargill Kettle, Esquire, S.M., of Auckland : Greeting. Whereas by a Commission bearing date the sixteenth day of December, one thousand nine hundred and twelve, you, the said Charles Cargill Kettle, were appointed to be a Commissioner, with the powers mentioned therein, for the purpose of making inquiry into matters affecting the administration of the St. Helens Hospital at Auckland : And whereas by the said Commission you were directed and required to transmit to me your report and recommendations in regard to the several matters inquired into not later than one month from the date thereof : And whereas the time within which you were required to report was extended first to the sixteenth day of February, one thousand nine hundred and thirteen, again to the sixteenth day of March, one thousand nine hundred and thirteen, and again to the thirty-first day of March, one thousand nine hundred and thirteen : And whereas it is expedient that the said period should be extended as hereinafter provided : Now, therefore, I, Arthur William de Brito Savile, Earl of Liverpool, the Governor of the Dominion of New Zealand, acting by and with the advice and consent of the Executive Council thereof, and in exercise and pursuance of every power and authority enabling me in this behalf, do hereby extend the period within which you shall (using all diligence) report to me, as by the said Commission provided, to the fifteenth day of April, one thousand nine hundred and thirteen.

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And with the like advice and consent, and in further pursuance of the said power and authority, I do hereby confirm the said Commission, except as altered by these presents. Given under the hand of His Excellency the Right Honourable Arthur William de Brito Savile, Earl of Liverpool, Knight Commander of the Most Distinguished Order of Saint Michael and Saint George, Companion of the Royal Victorian Order, Governor and Commander-in-Chief in and over His Majesty's Dominion of New Zealand and its Dependencies; and issued under the Seal of the said Dominion, at the Government House, at Wellington, this twenty-eighth day of March, in the year of our Lord one thousand nine hundred and thirteen. A. L. Herdman, For Minister of Hospitals and Charitable Aid. Approved in Council. J. F. Andrews, Clerk of the Executive Council. EEPOET. To His Excellency the Right Honourable Arthur William de Brito Savile, Earl of Liverpool, Knight Commander of the Most Distinguished Order of St. Michael and St. George, Member of the Royal Victorian Order, Governor and Commander-in-Chief in and over His Majesty's Dominion of New Zealand and its Dependencies. I, Charles Cargill Kettle, the Commissioner appointed by Your Excellency's Commission issued under the Commissions of Inquiry Act, 1908, and dated the 16th day of December, 1912, have the honour to submit my report on— (1.) The circumstances surrounding the death at St. Helens State Maternity Hospital at Auckland of Mrs. Laura Elizabeth Chamberlain; and (2.) Generally as to the administration of the said St. Helens State Maternity Hospital. 1. Mrs. Chamberlain's Case. Mr. A. E. Skelton, who appeared as counsel for the Auckland Timberworkers' Union, lodged, on behalf of the union, the following complaints with regard to Mrs. Chamberlain's treatment while she was in the Hospital from the 10th August, 1912, to the date of her death on the 9th September, 1912, viz. :— (1.) That the said Mrs. Chamberlain having sustained a rupture of the perinseum and serious injury to the soft parts during her confinement, it was the duty of the Matron of the said Hospital to immediately send for and obtain the services of a registered medical practitioner, but that the said Matron failed to send for or obtain the services of such medical practitioner until the third day after such injuries were sustained; (2.) That the said Matron further failed in her duty to call in medical advice when she discovered that such patient was suffering from puerperal septicaemia; (3.) That the said Matron, without the assistance of a registered medical practitioner, sutured the torn part of the perinaeum in some three or four places;

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(4.) That Dr. Tracy Inglis, in his capacity of Medical Officer to such institution, declined to allow the said Mrs. Chamberlain to be examined or her condition ascertained by another registered medical practitioner when a request for such examination was made by the husband of the said Mrs. Chamberlain at a time when her life was in grave danger; and (5.) That during the confinement of the said Mrs. Chamberlain the Matron of the said Hospital failed to provide her with the necessary and ordinary care, comforts, and requirements of such cases, and that in consequence thereof the said Mrs Chamberlain sustained unnecessary pain and suffering. The circumstances surrounding Mrs. Chamberlain's death were gone into very fully during the inquiry, but owing to the destruction of nurses' dailyreport books and the neglect to keep and preserve proper records at the Hospital I have not been able to obtain an entirely satisfactory and reliable history of the case, Or the particulars in detail of the patients' condition and treatment de die in diem. Dr. Inglis, the Medical Officer, did not keep a satisfactory record of his visits to the patient, the examinations which he made, and the course of treatment and diet ordered. The Matron during her evidence said (see page 84), " It is not possible for me or the doctor or submatron to give a detailed account of Mrs. Chamberlain's case from her admission till her death, except from memory." According to the case-book (Case No. 1325, written up some considerable time after Mrs. Chamberlain's death), and the temperature-chart (Exhibit 3), Mrs. Chamberlain was admitted to St. Helens Hospital on the 10th August, 1912, and on the following day gave birth to a male child. During the delivery the perinaeum was ruptured, and the Matron (Miss Ludwig) sutured it. According to the evidence of the Matron and Medical Officer the union was complete and the tear healed quickly. The patient's temperature and pulse rose on the day after delivery and continued to rise (see chart). Dr. Inglis stated that he examined the patient on the 12th August, and came to the conclusion that she was suffering from broncho-pneumonia. On the 13th August the patient was removed to Ward or Room No. 3, shown on plan Exhibit 2, and as her temperature' continued to rise (see chart) she was removed on the 24th August to the isolation ward outside the main building. Dr. Inglis continued to treat the case up to the 28th August as one of broncho-pneumonia. On that date he took ill and was confined to his bed. He asked Dr. Goldstein to attend the patient. Dr. Goldstein accordingly attended her from the 28th August to the Ist September. After examining her on the 28th August Dr. Goldstein discussed the case with Dr. Inglis, and on the same day Dr. Inglis wrote out a notice (Exhibit 58) to the District Health Officer at Auckland to the effect that he suspected that Mrs. Chamberlain was suffering from puerperal septicaemia. This notice was not, however, received by the District Health Officer till the 9th September. On the Ist September Dr. Goldstein called in Dr. Lindsay to consult with him as to Mrs. Chamberlain's condition. They examined the patient together, and apparently came to the conclusion that she was probably suffering from puerperal septicaemia. On the same day—viz., the Ist September —Dr. Inglis resumed duty and again saw the patient. He instructed Dr. Frost to make a blood test. This was done on the 3rd September, and Dr. Frost reported that it did not disclose the presence of streptococci. Dr. Frost then took a swab from the uterus and, having examined it, reported the presence of streptococci. Vaccine treatment was immediately adopted (see chart), but without success, and on the 9th September the patient died. On the 10th September Dr. Inglis certified in the usual form " that the cause of death was (a) puerperal septicaemia, and (b) heart-failure, and (c) that the time from attack till death was twenty days." (See Exhibit 59.) With regard to complaint No. 4, Dr. Inglis admitted that he refused to hold a formal professional consultation with Dr. Brockway, Mr. Chamberlain's family medical adviser, as to Mrs. Chamberlain's condition and treatment (see Dr. Inglis's evidence, page 44 et seq. and 50).

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I am inclined to the opinion that, as Mrs. Chamberlain's condition was very unsatisfactory immediately after the birth of her child, and as her condition apparently grew worse as time went on, Dr. Inglis should have had a consultation with Dr. Brockway or another experienced and reliable medical practitioner on or about the 16th or 17th August, if not earlier, as to her condition and treatment, and that blood and swab tests should have been made some time before the 24th August, when, as already mentioned, she was removed to\the isolation ward. The evidence does not entirely satisfy me that every step was taken and effort made during the earlier stages of the patient's illness —say, up to the 28th August —to ascertain as far as possible the true cause or causes of her very high and increasing temperature. With regard to complaint No. 5, the evidence does not establish to my satisfaction that the Matron failed to provide Mrs. Chamberlain during her confinement — i.e., during labour—with the necessary and ordinary comforts and requirements. With regard to complaints Nos. 1, 2, and 3, the Matron, as already mentioned, sutured the rupture of the perinaeum. lam inclined to the opinion that it is not advisable that Matrons of maternity hospitals or midwives in private practice should be permitted to suture ruptures of the perinaeum or other injury of the soft parts except in cases of absolute necessity, or when the services of a medical practitioner cannot be readily obtained. (See Rules Central Midwives Board, London, page 17—Exhibit No. 21.) 2. Administration. The St. Helens State Maternity Hospital at Auckland was established in the year 1906 under the Midwives Act, 1904, since consolidated by Act 1908, No. 118. I forward herewith (a) plan of the site on which the present hospital is built (Exhibit No. 1); (b) plan of the building showing the ground floor, basement, first floor, and isolation ward (Exhibit No. 2). The brick portion of the building was built for a Mr. Gorrie (the original Crown grantee of the land) in 1854. In November, 1880, Mrs. Purchas, wife of the Rev. Dr. Purchas, bought the property from Mr. Gorrie, and in 1885 added the wooden portion of the building as it now stands. In 1897 Mrs. Purchas sold the property to Dawson and others, who used the building as an institute for the treatment of habitual drunkards by the " Hagey process." In February, 1899, Dawson and others sold the property to one John Leydon, who used the building as a boardinghouse until April, 1906, when it was purchased by the Crown for the St. Helens State Maternity Hospital. The evidence given during the inquiry by many medical men of standing clearly establishes that the building is quite unsuitable for a maternity hospital, and that the site on which the building is erected is not an entirely satisfactory one. The opinion of the District Health Officer (Dr. Makgill) on this point is clear and emphatic. He says (see page 85) that the building is " both old and unsuitable. As time goes on the risk of injury to patients from the structural defects of the building will not diminish : it will rather increase." Section 5 of the Midwives Act provides that " There shall be established in New Zealand one or more State maternity hospitals where pupil nurses can, on payment of the prescribed fee, be carefully instructed in all the duties required for the welfare of mother and infant during and immediately after childbirth." Section 18 of the Act provides that " The Governor may from time to time appoint fit persons to be examiners of pupil nurses "; and section 7 provides that " Examinations of pupil nurses in the prescribed (i.e., prescribed by the Act or by regulations made thereunder —see section 2) subjects shall be held at the prescribed times and places." Section 19 provides that " The Governor may from time to time by Order in Council gazetted make regulations— " (a.) Prescribing the subjects of examinations under this Act; ■ " (b.) Providing for the regulation of maternity hospitals and the training therein of pupil nurses:

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" (c.) Fixing a scale of fees to be paid by patients who come to maternity hospitals for confinement or who are attended as patients outside the hospital by pupil nurses on their admission to any such hospital and by midwives on registration; " (d.) Providing for the admission to maternity hospitals of women who are unable to pay the prescribed fees and for their treatment and attendance as out-patients; " (<?.) Regulating the use and non-use of any instrument and drug by midwives, and defining what shall be deemed to be malpractices by midwives; " (/.) Providing for the right of any society or person on account of the gift or annual subscription of the prescribed amount to nominate a patient at any maternity hospital free of cost; and " (g.) Generally providing for anything which by this Act is expressed to be prescribed or which the Governor considers necessary in order to carry out the purposes of this Act." The only regulations made under the Act are those published in the New Zealand Gazette No. 39, of 27th April, 1905, pages 1022 and 1023 (see Exhibit No. 64 and Dr. Valintine's evidence, page 304). No examiners of pupil nurses have been appointed by the Governor under section 18 of the Act (see Dr. Valintine's evidence, page 79). The examinations have apparently been held by examiners appointed by the Inspector-General of Hospitals, and not in the manner prescribed by the Act. Under these circumstances it may be a question whether certificates heretofore issued to pupil nurses under the Act (see sections 4 and 8) are valid. Section 18 of the Act provides that the Governor may from time to time appoint fit persons to be Matrons of maternity hospitals established under the Act, and No. 5 of the beforementioned gazetted regulations provides that every maternity hospital shall be under the charge of a Matron appointed under the Act who shall have full control of the institution subject to the directions of the Minister. With regard to the appointment of the present Matron (Miss Ludwig), Dr. Valintine said (see his evidence, page 81), " She was appointed by Mr. Fowlds. There was no appointment by the Governor. There was no Cabinet minute. The appointment was made by the Minister without the Governor's warrant and without a Cabinet minute. The submatron was appointed in the same way. There is nothing in the Act with regard to submatrons." Miss Broadley is at present acting as submatron at the Hospital. There are no provisions in the Act or gazetted regulations relating to the appointment of submatrons. The Act does not provide for the appointment of a " Medical Officer," but No. 9 of the gazetted regulations provides that for every maternity hospital medical practitioners shall be appointed by the Governor annually to deliver lectures (not less than one every two weeks) to the pupil nurses, and by Regulation No. 10 of the same gazetted regulations such practitioners are required (a) to take pupil nurses out to cases of labour when practicable, and (b) to attend cases of labour in the hospital which are abnormal or which require the administration of an anaesthetic. It appears that Regulation No. 9 has not been complied with. Dr. Tracy Inglis has apparently been acting as " Medical Officer " of the St. Helens State Maternity Hospital in Auckland from the time the Hospital was opened in the year 1906 up to the present time, but it is at least doubtful whether his appointment was made in accordance with law (see his evidence, page 30 et seq and page 42). With regard to the general management of the Hospital by Miss Ludwig, the present Matron, who has been in charge since February, 1910 (see her evidence, page 33), the evidence justifies me in reporting that, having regard to the very unfavourable conditions under which the work has been carried on, there is no real ground for complaint. Tarn inclined to the opinion that

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the Matron has at times been overworked, and that having regard to the very responsible position which she holds her remuneration of £120 per year is not adequate. The submatron (Miss Broadley) gave evidence during the inquiry. She appears to me to be a thoroughly reliable, capable, and zealous officer. Her salary is only £80 per annum. The evidence satisfies me that the certificated nurses and pupil nurses have performed their duties satisfactorily, and have had a proper appreciation of their duties and responsibilities. I forward herewith the following statistics, dated from the opening of the Hospital in 1906 and completed to the present time, viz. : (a) Indoor cases; (b) outdoor cases; (c) patients transferred to the General Hospital; (d) deaths, 1906 to date; (c) septic cases, 1906 to date; and (f) lectures delivered in 1911 and 1912. (See Exhibit No. 61—A, B, C, D, E, and F.) It must be admitted that the results as shown by these returns are most satisfactory. Dr. Makgill, the District Health Officer at Auckland, referring to them said (see page 85), " I have seen the statistics of the home. I have compared them with statistics from other countries. Those of St. Helens are extraordinarily favourable to New Zealand and to Auckland. I think it is a great feather in the cap of the staff that they have kept the mortality and sickness returns so low, considering that they are the people who have suffered from the fact that their work has to be done in a building both old and unsuitable." (See also Dr. Valintine's evidence, page 79 et seq.) Mr. A. E. Skelton, counsel for the Timber-workers' Union, and Mrs. Nicol commented strongly on the destruction by or under the order of the Matron of certain records —viz., nurses report-books, Medical Officer's diary and charts, as stated in the evidence. In my opinion such records should not be destroyed except under the sanction of regulations made under the Act. The Matron stated on oath, and I have no reason to doubt her sworn testimony, that she destroyed the records without authority but under the honest belief that she was fully justified in doing so. She also stated that when she destroyed them she did not know or suspect that an inquiry such as the present one would be held. Questions were raised by the parties, especially by Mr. Skelton, during the inquiry as to (a) the suturing of ruptures of the perinaeum or other serious injury of the soft parts by Matrons, certificated nurses, and pupil nurses; (b) the administering of drugs to patients by Matrons, certificated nurses, and pupil nurses without the express authority and directions of a medical practitioner; (c) the delivery of Women by registered nurses and pupil nurses; and (d) the holding of consultations between medical practitioners in the event of the serious illness of patients or at the request of patients or their husbands or relatives. In my opinion these questions should receive early and careful consideration, and should be clearly and exhaustively dealt with by regulations to be made under the Act. During the inquiry Mrs. Nicol asked me to consider the following suggestions made by her, viz. : (a) That a resident Medical Officer should be appointed; (b) that the Medical Officer should not be in practice as a surgeon outside the Hospital; (c) that persons seeking admission to the Hospital should be entitled to appeal to a Magistrate or Inspector if refused admission by the officer in charge or in the event of the terms of admission as to fees, &o, being unsatisfactory to them, and that a Magistrate or Inspector should be empowered to order the admission of the appellant on such terms and conditions as he might impose; and (d) that patients should be admitted a reasonable time before labour commences. With regard to the suggestions (a) and (b) there is not in my opinion any necessity at present for the appointment of a resident Medical Officer, and I can see no reason why the Medical Officer of the institution should be prohibited from practising as a surgeon outside the Hospital, provided he takes the usual well-recognized and necessary precautions to prevent the spread of sepsis. &o.

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As to suggestion (c), I see no objection to applicants having such right of appeal; and as to suggestion (d) the gazetted regulations should, lam inclined to think, provide for the admission of a patient, in case of necessity, before labour comes on, on the certificate of an Inspector, medical practitioner, or Matron. During the inquiry Mrs. Nicol laid before me the following complaints : — Re Mrs. Porch : — 1. " That in the case of one Mrs. Porch the patient was placed in the isolation ward immediately after the removal of the body of a woman (Mrs. Chamberlain) who had died from septicaemia, and was attended by the same nurse as had attended the deceased." 2. " That Mrs. Porch took a chill on the labour-board which caused a severe cough, and she had an abnormal labour of sixty-five hours without a doctor being called in to see her or relieve her." 3. " That during this protracted labour she had no sleep." Re Mrs. March : — 4. " That in the case of one Mrs. Marsh the relatives of the patient were wrongly informed that she was suffering from scarlet-fever, and, further, were not informed in sufficient time before the patient's death to enable them to communicate with her." Re Mrs. Reed : — 5. " That in the case of one Mrs. Reed application was made for her admission, but was refused, although her husband was in poor circumstances and lived in a congested area and the case was a proper one, for admission." Re Mrs. Allen :— 6. " That in the case of one Mrs. Allen the patient was torn during labour, and stitches were put in by the Matron." 7. "That during her two confinements at St. Helens Hospital on 23rd November, 1911, and on 31st October, 1912, she received no visits from the doctor." 8. " That her baby was ill when discharged from St. Helens, and after two or three days she took it back to St. Helens for treatment, and the Matron told her to take the baby to a chemist. The chemist told her to take the baby to the General Hospital, where it has since died." Re Mrs. Catchpole : — 9. " That Dr. Inglis did on the 4th day of February, 1913, send and caused to be admitted into St. Helens Hospital a private patient of his own named Mrs. Amelia Catchpole, who was suffering from delirium tremens. On sth February Mrs. Catchpole was transferred from St. Helens to the General Hospital, where she died on the following day, the death certificate stating that the cause of death was delirium tremens." General: — 10. That the JVlatron has on several occasions refused to admit patients unless at least £1 was paid, and that this practice should be discontinued." Nos. 5 and 10 of these complaints were withdrawn and abandoned by Mrs. Nicol during the inquiry. With regard to all these complaints the facts are very fully set forth in the evidence. Complaint No. 1, re Mrs. Porch : It was admitted that Mrs. Chamberlain's body was removed from the isolation ward on the 10th September, 1912, at 8.30 a.m.; that Mrs. Porch was placed in the same ward in the evening of the same day; that she was attended by the same nurse (Nurse Adams) as had attended Mrs. Chamberlain; and that Mrs. Porch was removed to the General Hospital on the 18th September suffering from a pelvic abscess (see Admissions, Exhibit No. 70). It was, however, proved that the isolation ward was disinfected and fumigated after Mrs. Chamberlain's body was removed and before Mrs. Porch was put into the ward. With regard to complaints Nos. 2 and 3, the evidence does not establish that Mrs. Porch took a chill on the labour-bed which caused a severe cough.

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It was, however, admitted that the labour was protracted. It began at 1.30 a.m. on the 28th August and ended at 5.25 p.m. on the 30th August, when Dr. Goldstein attended the patient and delivered the child, using instruments (see copy case-book, case 1338 —Exhibit 52). The perinaeum was ruptured (second degree) and sutures were inserted. I am inclined to the opinion that the Medical Officer or another medical practitioner should have visited and examined the patient after she had been in labour for twenty-four hours, and should have conferred with the Matron as to what, if anything, should be done to hasten delivery or for the relief of the patient. Complaint No. 4, re Mrs. Marsh : The evidence is not sufficiently conclusive to justify me in holding that this complaint has been established. Complaints Nos. 6, 7, and 8, re Mrs. Allen and her child : The case-book (Exhibit 69a —Case No. 1138) shows that Mrs. Allen was confined at the Hospital in November, 1911; that the perinasum was ruptured (first degree); that a suture was inserted and the union was complete. On the occasion of her second confinement, in October, 1912, there was apparently no rupture of the perinaeum (see case-book—Exhibit 69, case No. 1376). The evidence does not satisfy me that when the patient was discharged her infant was ill and unfit to be discharged, or that when Mrs. Allen afterwards took the infant to the Hospital to get advice from the Matron as to the child's condition and treatment the Matron told her to take the child to a chemist. The evidence on this complaint was very conflicting. Complaint No. 9, re Mrs. Amelia Catchpole : The facts are fully stated in the evidence of Dr. Inglis at page 95 et seq. During the inquiry Mr. W. 0. Stevenson lodged the following complaint (Exhibit No. 71) :— To Mr. Kettle. Dear Sib, — 26th January, 1913. Being interested in the inquiry now being conducted re St. Helens Hospital, I have a case to state which I would like to have investigated and two questions answered. It is that my late wife (Mary Stevenson), who was confined in St. Helens on May 11th, 1912. She was in good health previous to being confined, and when taken to the Hospital was stripped of her flannel underclothing and clad in only an ordinary nightdress. She was confined an hour and a half after being admitted, placed in a room by herself which opened on to the balcony and provided a traffic-way for nurses and patients alike. After being in the above room for four or five days she was removed into a room in which there were two other patients, and which room was, in my opinion, about 11 ft. square and had two windows which were constantly open, and to which fact I attribute the fact of her catching cold, which developed into pneumonia in double form. She was discharged on the twelfth day as better, but she was taken ill the same night and had to be taken to the Public Hospital practically dying, being ordered there by Dr. McDougall, who said her complaint had not come on in one night, but had been coming on. Dr. Abbott, of the Public Hospital, held out no hope for her for three days, and then she rallied, but being so weak her system could not stand the strain; she developed a loss of reason, and finally died on July 31st, 1912, in the Mental Hospital, after being there for seven weeks. The baby only lived five weeks for want of proper care, as the mother could not give it sufficient food, as was proved during the short time it lived after the mother was taken away. I can obtain evidence of her condition when discharged, being escorted home by her sister, Mrs. G. D. Carmody, of 43 Richmond Road, Ponsonby, and another lady who said she was trembling when she was talking to the Matron. I can verify my case by the statements of her sisters and neighbours, among them being a nurse. Now, sir, there are two questions which I would like to have answered: (1.) Why was she discharged inside the two weeks when her condition was or must have been known to the staff? (2.) If they did not know, why did they not take steps to ascertain her true condition? There was also a nurse sent for from St. Helens, who said they had discharged her as being fit to come out. I think, sir, I have stated nry case as clearly as possible, but owing to being out of town on relieving duty on the railway at Pukekohe I cannot appear in person without a subpoena, as the Stationmaster said it was the only condition on which I can obtain leave, and if it is necessary to appear you can take what measures you may deem advisable. I am, ifec, W. O. Stevenson, Porter, Pukekohe. Mr. Stevenson appeared before me, and his complaint was fully investigated. After the evidence was given he stated that he was satisfied that his complaint had been thoroughly investigated. He said he would send me a statement from a Mrs. Poole, and that, subject to that, he had no further evidence to offer. Mr. Stevenson has not sent in Mrs. Poole's statement, although

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he was requested to do so, in writing, by me. The facts are fully and sufficiently disclosed in the evidence (see evidence of Mr. Stevenson, page 74 et seq and 75; Dr. McDougall, page 74 et seq; Dr. Abbott, page 72 et seq; Bridget Carmody, page 73 et seq). Mrs. Stevenson was allowed to leave the Hospital within fourteen days without the Medical Officer's consent being obtained. The Matron stated that in her opinion Mrs. Stevenson was in a fit condition to be discharged, that she was anxious to return to her home, and that her husband did not object to her leaving the Hospital. During the inquiry I received a letter from " a mother " (see Exhibit No. 73) making the following suggestions : — (a.) " Pupil nurses : Before a pupil nurse is admitted to the Hospital her health, moral character, and general fitness should be most carefully investigated by the authorities, and her application should be accompanied by a certificate from a reputable medical man and an Inspector or Magistrate that she is a person of good repute and a fit and proper person to be admitted as a pupil nurse." (b.) " Age of pupil nurses : No pupil nurse under the age of, say, twentyone years should be admitted." (c.) " The Matron and nurses should be required to wear a suitable hospital uniform and badge when on duty in or outside the Hospital." 3. Recommendations. Your Excellency's Commission invites me to accompany my report with such recommendations as I think fit to make in respect of the matters and things inquired into by me. I have therefore the honour to submit for Your Excellency's consideration the following recommendations :— 1. That if it is considered desirable to continue the State Maternity Hospital in Auckland in lieu of or in addition to maternity wards at the General Hospital (see section 61, subsection 1 (c), Act 1909, No. 2), a new up-to-date and properly equipped building with a nurses' home and lecture-room should be erected as soon as practicable on the present site in Pitt Street, or preferably on a more suitable site if one can be obtained. 2. That the nurses' quarters be provided with a library containing all the best and latest text-books and publications on maternity nursing, midwifery, and obstetric practice. Midwifery wall-diagrams for the use of lecturers, officers, and pupil nurses should also be provided. 3. That the Matron and submatron be provided with modern midwiferybags with sterilizer, &c. 4. That the Inspector-General under the Hospitals and Charitable Institutions Act, 1909. should be ex officio Chief Inspector of State Maternity Hospitals. That District Health Officers should be ex officio Deputy Inspectors of such hospitals. 5. That the Act and regulations thereunder be carefully and thoroughly revised. 6. That the regulations to be made under the Act should deal with {inter alia) the following matters : — (a.) Regulating the admission and discharge of patients (married women only) entitled to the benefits of the institution, and the attendance on out-patients. (b.) The maintenance of discipline, order, decency, and cleanliness among the officers, pupil nurses, and inmates of the institution. (c) Prescribing the duties, powers, and authority of Inspectors, Matrons, submatrons, nurses, pupil nurses, attendants, and servants of the institution. (d.) Prohibiting the suturing by Matrons of ruptures of the pernaeum and other soft parts when the services of the Medical Officer or a medical practitioner can be readily obtained. (c.) Preventing trespass upon the premises of the institution, or the grounds attached or belonging thereto.

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(/.) Prohibiting the introduction of any specified article or thing into the institution. (g.) Specifying the books, including case-books, nurses' report-books, prescription-books, diet and temperature sheets, complaint-book, visitors' book, &c, which are to be kept in the institution, and the manner in which such books are to be kept and preserved, &c. (h.) Defining the duties of all medical practitioners appointed by the Governor under Regulation No. 9 of the gazetted regulations. (Note. —See duties, &c, of Prison Medical Officers as set forth in Prison Regulations, No. 118 et seq.) (i.) Prescribing the times and manner in which the institution and the wards thereof shall be disinfected and fumigated, and also providing for the thorough sterilizing of all instruments, utensils, &c. (;".) Providing for the appointment of Inspectors and the frequent and thorough inspection of the institution and the books, &o, required by the regulations. (k.) Providing for the holding of consultations between Medical Officers and other medical practitioners as to the condition and treatment of patients in the case of serious illness or operations. (I.) Generally making provision for all matters referred to in section 19 of the Act and all other matters affecting the care and treatment of patients, and the management, control, and superintendence of the institution and the fulfilment of the purposes thereof. (m.) Providing for a breach of any such regulation a fine not exceeding, say, £10. 7. That the Act and all regulations made thereunder be printed and posted in convenient and conspicuous places in the institution, and a copy thereof delivered to every officer, pupil nurse, and servant. 8. That, if necessary, the certificates heretofore granted and issued to pupil nurses under the Act be validated. 4. Conclusion. During the inquiry important questions were raised as to the right of parties to the inquiry to inspect certain case-books and charts, and as to my power as a Commissioner to order and permit the inspection thereof before and during the inquiry. At the request of all parties I stated a case, agreed on by them, for the opinion of the Supreme Court under section 10 of the Commissions of Inquiry Act, 1908. A copy of the Special Case, together with the order made thereon by the Hon. Mr. Justice Cooper, is forwarded herewith. With regard to the costs of the inquiry, I am of opinion that the whole of such costs, including the costs of the parties thereto, should be borne and paid by the Hospitals Department. The inquiry into the matters referred to me lasted much longer than was anticipated. This was due almost entirely to the fact that on two occasions Mr. Mays, who appeared for the Crown Solicitor, applied for and obtained adjournments to enable him to attend to other public business, and on one occasion, owing to Mrs. Nicol's illness, a further adjournment was necessary. I return to Your Excellency the Commission with which you honoured me, together with (a) minutes of the proceedings; (b) the notes of the evidence (400 pages) taken during the inquiry and bound in four volumes; and (c) the exhibits put in evidence during the inquiry, and a schedule thereof. In witness whereof I have hereunto set my hand, this sth day of April, 1913. Chas. C. Kettle, S.M., Commissioner.

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In the Supreme Court of New Zealand, Northern District. Lb the matter of the Commissions of Inquiry Act, 1908, and in the matter of a Commission given under the hand of His Excellency the Administrator of the Government, and issued under the seal of the Dominion of New Zealand, appointing the undersigned Charles Cargill Kettle, Esquire, a Commission to inquire and report as to —(1) The circumstances surrounding the death at the St. Helens Hospital, Auckland, of Laura Elizabeth Chamberlain; and (2) generally as to the administration of the said St. Helens Hospital (a copy of which said Commission is hereto attached). Special Case stated by the Parties on a Disputed Point of Law arising in the Course of the Inquiry and referred to the Supreme Court by the Commission at the Request of the Parties for Decision under Section 10 of the above-intituled Act. 1. The inquiry was set up at the request of and in consequence of certain allegations made by — (a) The Auckland Timber Workers' Industrial Union of Workers; and (b) Mrs. Emily Nicol. These parties are hereinafter referred to as " the complainants." 2. When the inquiry opened the following parties appeared or were represented : (1) and (2) The complainants; (3) the Medical Officer, the Matron, and staff of St. Helens Hospital, Auckland, and the Inspector-General of Hospitals (all hereinafter referred to as " the Hospitals Department "), who are respondents to the complaints and allegations. 3. St. Helens Hospital at Auckland is a State Maternity Hospital established under the Midwives Act, 1904. 4. During the course of the inquiry the Hospitals Department brought into Court, at the request of the complainants and by direction of the Commissioner, three "case-books" and a number of temperature-charts relating to the cases and treatment of patients in the said St. Helens Hospital in respect of whom complaints were filed. Ihe said case-books cover a period from the 24th day of April, 1910, to the 26th day of December, 1912, and contain the names and addresses, and in some cases the medical and family history, of all the patients treated in the said Hospital between the above dates, and also in some cases the particulars of the treatment given in the said Hospital. Some of the facts set out in the said case-books were communications made by such patients to the Matron and nurses of the said Hospital. The said case-books were written up almost entirely from the original notes kept separately by the nurses and the Matron for each individual case, and each case in the case-book was so written up in some cases some weeks after the discharge of the patient. All the said original notes up to the 22nd day of October, 1912, have been destroyed by the said Matron. The temperature-charts cover a period from Ist April, 1912, to February, 1913, and are a record of the temperature, pulse, and respiration movements of the various patients treated during that time. In some cases these charts show the special medical treatment of the patient. The said case-books and charts will be produced before this honourable Court on the argument hereof. 5. The Medical Officer of the Hospital is a duly qualified medical practitioner, and the regulations direct that he shall attend those cases of labour which are abnormal, or which require the administration of an anaesthetic. The Matron is a nurse registered under the Nurses Registration Act, 1908, and a midwife registered under the Midwives Act. Without medical assistance or supervision, she attends and is responsible for the treatment of all cases of labour other than those which the regulations require to be attended by the Medical Officer. The term " Matron " shall include the submatron, who has the same qualifications, and who in the absence of the Matron performs similar duties. 6. The pages containing the medical history of the said six specific patients which came under the review of the Commission are bound up with numerous other cases in the three casebooks already referred to, but during the course of the inquiry only those pages and charts which related exclusively to the said six specific patients were examined by the Commission, the complainants, and counsel for the Department. The complainants now claim — 1. That without the consent of the patients they have an absolute right to examine all the entries in all the said case-books and charts, and to use such of the information obtained thereby as they may think fit for the purposes of the inquiry. 2. That if the complainants have not such absolute right, then the Commission, without the consent of the patients, has the power at its discretion to order that the whole of the said books and charts be produced for inspection, and that the complainants be permitted to inspect them. Counsel for the Department denies — (1.) That the complainants have such right as aforesaid; and • (2.) That the Commission has such power as aforesaid. Pending a decision on the above points of law in dispute, the Commission has not allowed the complainants to inspect the said books and charts otherwise than as aforesaid. The questions for the decision of this honourable Court are : — (1.) Whether, if any of the entries in the said case-books are communications made by patients to the Medical Officer should they be discovered or admitted in evidence. (2.) Are the complainants entitled as of right to inspect the said books and charts. (3.) Has the Commission power under the Commissions of Inquiry Act, 1908, or under the Magistrates' Courts Act, 1908, on the application of any party to the proceedings, to order the inspection of the said books and charts before or during the inquiry? (4.) If the Commission has power to order such inspection, should such inspection be limited to any particular case or matter?

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(5.) Whether, when the books have been produced before the Commission by a witness on a summons duces tecum issued by the Commission, the Commission has power to order that a party to the inquiry be allowed to inspect the books when produced generally and take notes or extracts therefrom ? Dated at Auckland this 13th day of March, 1913. C. C. Kettle, S.M., Commissioner. In the Supreme Court of New Zealand, Northern District. In the matter of the Commissions of Inquiry Act, 1908, and of the St. Helens Hospital (Auckland) Inquiry. Thursday, the 20th Day of March, 1913. Upon reading the special case stated by the parties on a disputed point of law arising in the course of the inquiry, and referred to this honourable Court by the Commission under section 10 of the above-intituled Act, and upon hearing Mr. A. E. Skelton, of counsel for the complainants, and of Mr. Mays, of counsel for the Hospital Department, this Court doth order that the questions submitted for decision be answered as follows :— Question No. I. —Whether, if any of the entries in the said case-books are communications made by patients to the Medical Officer should they be discovered or admitted in evidence? Answer. —No. These communications (if any) should not be discovered without the consent of the patients. Question No. 2. —Are the complainants entitled as of right to inspect the said books and charts ? Answer. —Subject to answer to question No. 1, the complainants are entitled to apply to the Commissioner for leave to inspect any books and charts dealing with the subject-matter of the Commission, and the Commissioner must exercise his discretion as to whether he shall grant such leave. Question No. 3. —Has the Commission power under the Commissions of Inquiry Act, 1908, or under the Magistrates' Courts Act, 1908, on the application of any party to the proceeding, to order the inspection of the said books and charts before or during the inquiry? Answer. —Subject to answer to question No. 1, the Commissioner has the same power as a Magistrates' Court, under section 83 of the Magistrates' Court Act, 1908. Question No. If. —If the Commission has power to order such inspection, should such inspection be limited to any particular case or matter ? Answer. —This is within the discretion of the Commissioner. Question No. 5. —Whether, when the books have been produced before the Commission by a witness on a summons duces tecum issued by the Commission the Commission has power to order that a party to the inquiry be allowed to inspect the books when produced generally, and take notes or extracts therefrom. Answer. —Subject to answer to question No. 1, the Commissioner may make such order as he deems just. By the Court. R. G. Thomas, Registrar.

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MINUTES OF PEOCEEDINGS. Monday, 16th December, 1912 (Preliminary Sitting). Mr. C. C. Kettle, S.M., Commissioner. Parties— 1. Mr. Mays lor Hospitals Department and St. Helens staff. 2. Mr. A. E. Skelton for Auckland Timber-workers' Union. '3. "Mrs. Nicol. Miss Maclean, Assistant Inspector of Hospitals, present. Adjourned to 18th December, 1912. (After adjournment, Commissioner and others visited and inspected St. Helens Hospital, buildings, &c.) Wednesday, 18th December, 1912. Commissioner reads Commission received by him this morning. Present :— 1. Mr. Mays (instructed by Crown Solicitor), representing Hospitals Department and also appears for St. Helens staff, Dr. Inglis, and Miss Ludwig. 2. Mr. A. E. Skelton, i-epresenting relatives of deceased, Mrs. Chamberlain, and Auckland Timber-workers' Union. 3. Mrs. Nicol informs Commissioner that she will not appear further till provided with counsel. She says she was promised counsel by Mr. Bradney, M.P., who she says has a telegram from Wellington to the effect that she will be provided with counsel. She also says she wishes to appear by counsel to prove the charges she has made, she being the only person who has made charges. 4. Mr. Richard Knaggs, labourer, of St. Helier's Bay, who wishes to appeal' for his daughter if no other arrangements made for other parties to appear. Mrs. Nicol says she has the case in hand. Mr. Knaggs states he withdraws, and leaves matter in Mrs. Nicol's hands Commissioner asks that all charges and names, &c, of witnesses required should be given in writing. Mr. Skelton says he will formulate and file charges re Mrs. Chamberlain. Commissioner asks Mrs. Nicol if she wishes to make any charges or complaints in connection with death of Mrs. Chamberlain. Mrs. Nicol would not reply, but asks for adjournment to enable her to get counsel. Mr. Skelton asks that Commissioner should take evidence and report on the building, equipment, &c, of the Hospital. Mr. Skelton asks for production of : — (a.) Mrs. Chamberlain's temperature-chart. (&,) Case-book containing history of Mrs. Chamberlain's case. (c.) Mrs. Chamberlain's night report. (d.) All reports of nurses concerning Mrs. Chamberlain, (c.) Correspondence between Mrs. Nicol and Inspector. (/.) Correspondence between Mrs. Nicol and Inspector-General (from Inspector-General) since reception of Mrs. Chamberlain into Hospital on 10th August, 1912, till present time. (.?.) Report of Matron of St. Helens to Public Health Department of Mrs. Chamberlain's death, and all other correspondence between Matron and that Department concerning Mrs. Chamberlain's death and treatment. (h.) Report made for Inspector of Hospitals on Mrs. Chamberlain's case by Miss Maclean. Commissioner asks Mrs. Nicol if she wishes anything produced. Mrs. Nicol says she can do nothing without counsel, and will not go further without counsel. Mr. May undertakes to provide copy of all documents, &c, asked for, and will hand them in later, with a schedule thereof. Tuesday, 14th January, 1913, at 10 a.m., fixed for next sitting. Mrs. Nicol asks what about charges she has already made to Prime Minister and Hon. Mr. Rhodes. Commissioner says that every charge she wishes to formulate will be inquired into. Mrs. Nicol says, " Very well, your Worship; I am satisfied." Adjourned to 14th January, 1913. Tuesday, 14th January, 1913. Present: — Mr. C. C. Kettle, Commissioner. Dr. Bamford appears as counsel for Mrs. Emily Nicol. Mr. A. E. Skelton for Auckland Timber-workers' Union.

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Mr. Mays for Department and for all parties against whom complaints are made. Complaints in writing by Mrs. Nicol handed in by Dr. Bamford. Complaints read. Complaints by Auckland Timber-workers' Union handed in by Mr. Skelton and read. Mr. May asked if charges made are all that it is intended to make. Mr. Skelton says he reserves the right to formulate other complaints during the inquiry, and that due notice of them will be given. With regard to No. 3 of Mrs. Nicol's complaints, Mr. Mays asks for names of persons refused admission to Hospital. Dr. Bamford undertakes to supply names later on, or abandon the charge. As to complaint No. 4, Mr. Mays asks for Christian name of Mrs. Reid. Dr. Bamford says " Charlotte " Reid. As to supplementary complaint of Timber-workers' Union, Mr. Mays asks for more particulars. Mr. Skelton : All will be made clear from Mr. Chamberlain's evidence. By consent, first matters to be dealt with are circumstances surrounding death of Mrs. Chamberlain. Mr. Skelton will lead evidence on this matter. Dr. Bamford says some witnesses in Chamberlain's case will give evidence in Porch's case. Decided to take cases separately. Mr. Mays puts in " Rules for Management of State Maternity Hospitals," at request of Commissioner; and regulations in Gazette of 27th April, 1905, made under Act by Governor in Council. Mr. Skelton expresses a desire to inspect the Hospital premises. Adjourned for one hour, to enable counsel to visit and inspect Hospital, and particularly "labour-table." Mr. Mays hands in plans of Hospital building, and of land, &c. " Rules for Guidance of Midwives " put in. Mr. Skelton opens, and evidence (in part) of following witness taken : —■ Thomas Chamberlain. Adjourned to 15th January, 1913.

Wednesday, 15th January, 1913. Evidence of following witnesses taken : — Thomas Chamberlain (concluded), Sadie Finer. Louisa Hunt. Walter Scott Brockway. Adjourned to 16th January.

Thursday, 16th January, 1913. Dr. Bamford, for Mrs. Nicol, states that she desires to withdraw charges Nos. 5 and 10. Evidence of following witnesses taken : — Frances Whliams. Minnie Hooker. Florence Keller. Adjourned to 17th January. Friday, 17th January, 1913. Evidence of following witness taken : — Kate Annie Underwood. Adjourned to 18th January.

Saturday, 18th January, 1913. Dr. Bamford asks for leave to retire from the inquiry. He says he does so at Mrs. Nicol's request. Leave to retire given. Mrs. Nicol (in person) says she has another complaint to put in, and that" she will conduct her own case by arrangement with Dr. Bamford. She asks for a return of cases transferred from St. Helens to the General Hospital during the last two years. Adjourned to 20th January. 3—H. 31b.

H.-318

Monday, 20th January, 1913. Mrs. Nicol hands in further complaint re Mrs. Allen. Complaint read. Evidence of following witnesses taken : — Angelina Allen. Marion Bowry. Tracy Russell Inglis. James White Hooker. Charlotta Ludwig. Tracy Russell Inglis (recalled). Florence Keller (recalled). Herbert M.,Goldstein. Tracy Russell Inglis (recalled). Adjourned to 21st January. Tuesday, 21st January, 1913. Mrs. Nicol hands in further complaints re Mrs. Porch. Complaints read. Evidence of following witnesses taken : — Angelina Allen (recalled). Charlotta Ludwig (recalled). Norman Albert Porch. Adjourned to 22nd January. Wednesday, 22nd January, 1913. Evidence of following witnesses taken :— Sabina Newcomb. Robert Brifi'ault. Tracy Russell Inglis (recalled). Martha Broadley. Isabella Thompson. Adjourned to 23rd January. Thursday, 23kd January, 1913, Evidence of following witnesses taken : — . Tracy Russell Inglis (recalled). Hilda Bryant. Tracy Russell Inglis (recalled). Adjourned to 24th January. Friday, 24tTH January, 1913. Evidence of following witness taken : — Tracy Russell Inglis (recalled). Adjourned to 27th January.

Monday, 27th January, 1913. Complaint from W. 0. Stevenson, railway porter, Pukekohe, received by Commissioner and read. Evidence of following witnesses taken : — Tracy Russell Inglis (recalled). Herbert M. Goldstein (recalled). Adjourned to 28th January.

Tuesday, 28th January, 1913. Mr. Mays asks for week's adjournment, as he must go to Helensville to attend compensation case before Mr. Justice Cooper. Mr. Skelton and Mrs. Nicol consent. Evidence of following witnesses taken : — Ebenezer Joseph Thomas. Charlotta Ludwig (recalled). Adjourned to 4th February, 1913.

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Tuesday, 4th February, 1913. Evidence of following witnesses taken :— Herbert M. Goldstein. Martha Porch. Tracy Russell Inglis (recalled). Adjourned to sth February Wednesday, sth February, 1913. Mrs. Nicol not present. Subsequently appears. Theodore Endletsberger examined. Mrs. Nicol asks leave to retire till the afternoon. Evidence of following witnesses taken : — Peter Alexander Lindsay. Charlotta Ludwig (recalled). Adjourned to 6th February. Thursday, 6th February, 1913. Evidence of following witness taken : — Charlotta Ludwig (recalled). Mr. Mays protests against parties looking through case-books and charts generally. Commissioner orders that books be not examined generally till matter argued and ruling given. Hanah Jones. Tracy Russell Inglis (recalled). Susie Way. Martha Broadley. Adjourned to 7th February. Friday, 7th February, 1.913. Evidence of following witnesses taken : — Tracy Russell Inglis (recalled). Charlotta Ludwig (recalled). William Norman Abbott. Bridget Carmody. Martha Broadley. William Oliver Stevenson. Neil McDougall. Hester Maclean. Adjourned to 10th February, 1913. Monday, 10th February, 1913. Evidence of following witnesses taken : — Henry Schofield. Hester Maclean (recalled). Martha Broadley. Ihomas Harcourt Ambrose Valintine. Adjourned to 11th February. Tuesday, 11th February, 1913. Evidence of following witnesses taken : — Ebenezer Joseph Thomas (recalled). Thomas Harcourt A. Valintine (recalled). Charlotte Ellen Josephine Adams. Adjourned to 12th February. Wednesday, 12th February, 1913. Evidence of following witnesses taken : — Charlotta Ludwig (recalled). Robert Haldane Makgill. Tracy Russell Inglis (recalled). Mrs. Nicol being too unwell to proceed, inquiry adjourned to 24th February.

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Monday, 24th February, 1913. At Mr. May's request, inquiry adjourned to 3rd March. Monday, 3rd March, 1913. Evidence of following witnesses taken : — Robert Grieve. Dr. Thomas Hope Lewis. Jessie Burns. Dr. Constance Helen Frost. Charles Evans Maguire. Adjourned to 4th March. Tuesday, 4th March, 1913. Evidence of following witnesses taken : — Thomas Copeland Savage, surgeon. Florence Keller (recalled). Adjourned to sth March. Wednesday, sth March, 1913. Evidence of following witnesses taken : — Dr. William Chisholm Wilson McDowell. Ethel Jakeman. Mabel Davis. Cornelius Little. Adjourned to 7th March, 1913. Friday, 7th March, 1913. Evidence of following witness taken : — Tracy Russell Inglis (recalled). At request of parties, case stated and settled for the opinion of the Supreme Court re inspection of books, &c. Adjourned sine die. Wednesday, 26th March, 1913. All parties present. Commissioner reads letter, dated 7th March, received by him from the secretary of the Auckland United Friendly Societies. Mrs. Nicol asks the Commissioner to call the persons mentioned in the letter —viz., Messrs. Nerheny, Beehan, McLeod, and Gray—as witnesses. Mr. Skelton states that, having given the matter very careful consideration, he admits that the dispute between the friendly societies and the British Medical Association is not a matter into which the Commissioner can be asked to inquire. The Commissioner ruled that he could not inquire into the dispute between the friendly societies and the British Medical Association, but that the letter received by him would be forwarded with the exhibits and his report. Mr. Mays handed in the order of the Supreme Court on the special case which had been stated by the parties. Mr. Mays contends that, apart from the decision of the Supreme Court, the Hon. Minister objects, on the grounds of public policy, to the case-books and charts being inspected by any one except the Commissioner. Agreed by all parties that Mrs. Nicol's address on the evidence be now taken, pending further discussion re inspection of case-books and charts. ' ■ •; . ' Mrs. Nicol commences her address. - Adjourned to 27th March, 1913. . . . Thursday, 27th March, 1913. Mrs. Nicol's address continued and concluded. Mr. A. E. Skelton addresses the Commissioner at considerable length, especially on the Chamberlain case. Mr. Mays does not wish to address the Commissioner. After discussion, Mr. Skelton says he does not now press his application to inspect the case-books and charts, but requests the Commissioner to carefully inspect them with a view of noting the number of cases in which there was a ruptured perinseum sutured by the Matron, &c. Inquiry concluded.

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MINUTES OF EVIDENCE. Tuesday, 14th January, 1913. Thomas Chamberlain, sworn, saith. 1 reside at 246 Ponsonby Road, Auckland. I am a timber-worker. I was husband of Laura Elizabeth Chamberlain. At the time of our marriage my wife was aged nineteen years. I had been acquainted with my wife for three years before our marriage. During those three years her health was the very best. Except on two occasions, she was very vigorous. She had a cold in May, 1912. She was better of that in a few days. She was not attended by any medical man for it. She had a slight complaint of the kidneys. Dr. Brockway told me that was due to pregnancy. He gave her medicine for it. She was all right in three or four days. She was a fine big strong young woman —bigger and stronger than 1 am. On 10th August, 1912, my wife went into St. Helens Home. The time was between 10 and 11 a.m. The child was born about 5 a.m. next day. My wife had made arrangements for her admission about two months beforehand. The child born was a male —a full-time child. My wife told me the weight was either 6£ lb. or 6| lb. —I forget which. I first saw my wife after her confinement about 3 in the afternoon of the same day. She was in, I think, room No. 9. There were two beds in the room. My wife was the only patient there —that is, in that room. [Witness is asked to state the conversation he had with his wife. Mr. Mays objects, on ground that no nurse was present. Evidence admitted, subject to decision later as to how it is to be used.] I made no note of our conversation. I speak from memory only. I asked my wife how she got on. She said, "Very fair." Shortly after this she started to cough. I said, "By Jove, you've got a bad cough." She said " Yes." 1 asked if she had caught cold. Her reply was, " Yes. I got a severe chill on the labour-table." She used those words. I asked her how that happened. Wasn't she well covered up. She said that she did have a covering over her, but it was very light. She complained about, it being very hard on the board—that the cover on that was very scant. I asked her what it was. She said it was a waterproof sheeting. She told me she was shivering when she was removed to the bed. She said she shivered in bed, and that there was an injection inserted into her hip while in bed. She told me it was very wet on the table. She also told me she was torn during labour, and that the Matron had put in four or five stitches. She told me that during confinement the Matron had not laid a hand on her till after the baby was born, and that one of the nurses in attendance on her met the Matron at the door as she was coming in and said something to her (the Matron), but she (my wife) did not hear what she said. The Matron replied to the nurse, "You should not have done that." The Matron attended her then, and put in those four or five stitches. She said the shivering continued for some time after she was put to bed. My wife's legs were not tied at that time, but she told me they were going to be tied. That is about all that took place between us on this occasion. I went along to the Hospital again the following evening. I went to my wife's room, and saw her. No nurse was present. It was in the same room. I asked her how she was going on. She said all right, but for a throbbing pain where the stitches were. She told me that the Matron told her that the stitches would be coming out on the ninth day. She seemed bright and all right on this occasion. I had not up to this asked her if she had been seen by the Medical Officer. The time was shortly after 7 o'clock. There were no other complaints that day. I visited my wife again on the following day at about the same time. I asked her how she was getting on that evening. She said, " Oh, lam all right, only for the throbbing pain of the stitches." She told me the doctor had seen her that day—Dr. Inglis, she said. She said that the Matron and doctor had stood at the foot of her bed speaking in a low voice. She said she did not hear what the conversation was. She said the doctor walked up to the bedside, took hold of her arm, and felt her pulse, and asked her if she was nervous. She replied " No." She said that he said " That is all right." I asked her if he had examined her otherwise. She said "No." That is all that took place that day. The next day I found that my wife had been shifted to another room. Ido not know the number of this room. [Witness points out room on plan (room No. 3).] I asked her. how she was doing on that occasion. She told me all right, but those stitches were still throbbing. I told her if she had any complaints to make to tell the Matron —not to tell any of the nurses, but to tell the-Matron. At this time the child was at the.breast. This was the first occasion I had seen the child at, the breast. I noticed nothing on this occasion when the child was put to the breast. My wife's condition was all right but for the pain of the stitches. I went on■ the fifth day at the usual time to see my wife. .She told me .the baby had been taken off the.breast that day. I asked her why, and she said she did not exactly know.. She said, she thought; it was because her left breast was sore. On the fifth day my wife pressed her breast. There was black blood and matter issued from it. I saw this myself. It was done in my. presence. . The, child was not allowed to continue on the breast after the fifth day that I know of. My wife told me that injections were made in her arms daily by the nurses. She told me on this day that the Matron had been pressing on her stomach, and told her that she seemed to have a lot of wind in her stomach. She said the Matron asked her if she suffered from wind in the stomach before she entered the home. She said she told the Matron "No." I had no conversation with the Matron on the fifth day. Luncheon adjournment. I had spoken to my wife before the third day as to attendance on her by a doctor. I asked her on the day of the confinement if a doctor was in attendance, or if she had seen one later on.

Jcl.—3lb.

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[T. CHAMBERLAIN.

She replied " No." I asked her on the second day if she had been seen by a doctor. She said " No." The third day was the first occasion, so far as I know, of attendance on her by a doctor. 1 went to see her as usual on the sixth day. She then told me that hot fomentations had been put to her breast; that was to put the milk away. She also told me that some of the stitches had been taken out on that day. She did not say how many. I never learnt afterwards if the others were taken out. I had no conversation with the Matron on the sixth day. Later on than the sixth day the Matron told me that my wife was getting a temperature. She (wife) made no complaint about the room about this time. Nurse Way was at this time in attendance on my wife. I do not know when she was first placed in charge of my wife. My wife told me about the sixth day that Nurse Way had to attend no other patient or wash any other patient but herself. I noticed one objectionable thing about room No. 3 —that was, that the room was made a thoroughfare of for getting to the balcony. My wife told me of this. I continued to visit my wife every night right up to the time of her death. She continued under Nurse Way till the 23rd August as far as I can fix the date. It was about that time that she was removed from, the building to the separate isolation ward. Nurse Way was removed with her to that ward. I saw the Matron that night, and discussed with her the question of my wife's temperature —the question of her condition. 1 was told on the occasion of the removal that Dr. Inglis had examined her. The Matron told me she was suffering from a bad chest complaint. I told her that 1 could not believe that, as she had never had any chest complaint that I knew of. The Matron also told me that the temperature was very high at that time; she said about 104: or 105. She asked me if I knew if my wife had been a healthy woman before she was married. I told her Yes, as far as I had known. So anxious had 1 become that I decided to call upon Dr. Inglis that night. I called on him at his house in Ponsonby Road. I told him I was the husband of the young woman, Mrs. Chamberlain, who was confined at St. Helens. I asked him if he could tell me what was the matter with her, as she had not sat up. He told me that he had examined her, and all he could find wrong with her was chest complaint of long standing, with a tendency to tuberculosis. I did not feel satisfied with this. I went the next day, in consequence, to my family doctor, Dr. Brockway. In consequence of our interview, Dr. Brockway rang up Dr. Inglis. 1 heard what Dr. Brockway said. He told Dr. Inglis that I would like him (Brockway) to go along and visit my wife. In consequence of the conversation, I went to see Dr. Inglis. I told him I. would like to get Dr. Brockway to see my wife as he was our family doctor. Dr. Inglis said he would not give Dr. Brockway admittance. I asked him why, and he said, for the first reason, he did not belong to the British Medical Association. I asked him if I could fetch along a British Medical Association doctor. He said " No." I asked the reason why. He said it was not required, and when it was required he would call in doctors, but he would select his own. I told Dr. Inglis that the reason why I wanted Dr. Brockway was that I was not satisfied about his diagnosis of the case. He told me that other men were always satisfied with their wives under his care. He said, " You are making a great fuss about your wife. You seem to think that she is of some special consequence." He asked me what I meant by getting doctors to ring him up all round the town. Things went on without being any better at all till the 31st August. On that day I went straight to the Matron in the evening. I told her I was not at all satisfied with the way things were going. She told me she did not think my wife was seriously ill. I told her I was not satisfied, and that they would have to make a move and get doctors in to hold a consultation. The Matron told me to go along and see Dr. Inglis. I told her I had seen him, and that he would not allow me to get doctors in. I told her that if they did not make some move I would do so on Monday—that I would go and get a solicitor's advice on it. Next day Dr. Goldstein took Dr. Lindsay along. Dr. Goldstein was temporarily in charge of the home. 1 did not see him on the Ist September. I saw him on the 2nd September. On the Ist September my wife was looking very ill and weak. From the eighth or ninth day after the confinement I noticed that my wife was looking very ill. It was in consequence of what I saw myself that I paid these visits to Drs. Brockway and Inglis. In her ordinary health, nvy wife was quite the reverse of despondent. On the Ist September I could see that my wife had made no progress towards health—she was going down all the time. On Monday, the 2nd September, I went along and saw the Matron. I asked her if she could tell me what the result was of all the doctors. She told me to go round and see Dr. Inglis or Dr. Goldstein, and that they would tell me pretty straight what was the matter. I went at once to Dr. Goldstein. I asked him what the case was. He asked me if Dr. Inglis did not tell me that my wife had chest complaint. I said, "Yes." He told me that he was of the same opinion—that he had taken Dr. Lindsay round, that he had examined her, and was of the same opinion too. He asked me if my wife had always been a strong woman. I told him that as far as I knew she had. I then asked him if there was any blood-poisoning about the case. He said he did not think so —that if I wanted to know any more I had better go round to Dr. Inglis, as it was his case, and that he was only working there a few days while Dr. Inglis was off sick. He also told me there had been a blood test taken from my wife, that it was taken to the public Hospital, and they would perhaps know more the next day. I did not see Dr. Inglis that night. I called on him the next morning. I told him what Dr. Goldstein had said. He told me that I had the advice of three doctors—himself, Dr. Goldstein, and Dr. Lindsay—and that they were all of the same opinion—that it was chest complaint of long standing. I asked him about the result of the blood-test. He told me the result was that the blood was as pure as could be —that there was no septicaemia, no erysipelas, or any other blood-poisoning. I saw my wife that night. She seemed very weak. Nurse Way was there till the 2nd September; then Nurse Adams, a trained nurse, was put on. She remained in sole charge until the end. I saw nothing at all from the 2nd September to lead me to think my wife was making any progress towards recovery. She had got very thin and weak, and very pale. I noticed an offensive smell about her. I noticed this about the eighth or ninth day after confinement. I remarked on it to her. I did not mention it to the Matron. My wife told me she thought it was from

23

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T. CHAMBERLAIN.]

medicine they were giving her. On night of 9th September I spoke to Nurse Adams. She told me she did not wish me to stay an} - time, as she had given my wife an injection of serum. I said " Serum." She said " Yes." I said, " That's for blood-poisoning, is it not." She said "Yes." I said I thought it was blood-poisoning, but the doctors had been trying to lead me to believe it was chest complaint. The nurse said, " Oil, well, Mr. Chamberlain, I do not know what it was for certain." She said she had never got it definitely from the doctors what it was. 1 went in and saw my wife, but did not stay any time. She appeared to me as if she would not live much longer. I spoke to her. She was really too weak to tell me how she felt. [ left after a very short vi:it. I was roused at my home by one of the nurses at 11.50 that night. She told me that the doctor had been along seeing my wife, and that she would not live more than a few hours. 1 caught the last car straight away. I got to the home about midnight, but my wife was then dead. 1 called at Dr. lnglis's house next morning for a certificate of death. I did not see the doctor. A lady came to the door to inquire about age, &c. She returned after that with a certificate of death. 1 saw it. [Certificate from case-book put in. Caes No. 1325 —indoor case. Copy of entries in case-book put in by consent.] I saw a chart in the isolation ward. As to the notes in the case-book, it is true that my wife's mother (Mrs. Underwood) was staying with us before my wife went to the Hospital. She came to us on the 17th June. She was then suffering from a bad leg. She had varicose veins. Dr. Brockway operated on her about a fortnight later. The wound was open for seven or eight days, then it started to heal up. It was healed up about three weeks before my wife went into the home. 1 saw it, and that it was healed. It is not correct that my wife dressed my mother-in-law's leg night and morning for several weeks. On several occasions I remember it being dressed by Mrs. Underwood herself, in the morning. The day after the leg was lanced my wife dressed the leg. Mrs. Underwood came to my house to lay up. My wife did not do any dressing—only on one occasion. I say this from what I learnt from my wife and my mother-in-law. I saw the leg dressed on most occasions. It was then dressed by Mrs. Underwood herself. On some days she only did it once a day. Apart from the varicose veins, Mrs. Underwood was throughout in the very best health. She left my house on the Bth August. It is certainly not true that my wife had a nasty cough on admission. It is not correct that she had influenza a fortnight before her admission She had neither signs nor symptoms of influenza before this. She was not suffering from anything at all on her admission. 'She had not been complaining to me as to her health. She used to be a little run down at night-time—on some evenings—that is, tired. On the night before she went into the Hospital I took her for a walk for a couple of miles. She seemed very well after it. I got tired first. She wanted to walk some distance further, but I was a little tired myself. Apart from her pregnant condition, my wife was apparently in good health, and in her normal good health. There were no complaints from her except as to being tired at nights. She had the assistance of her sister, a girl about twelve, in the house. She had no cough, no influenza at the time of her admission. My wife complained to me every evening after her confinement as to pain where the stitches were for nine or ten days. She did not complain of any pain in the chest when she coughed. She told me she had a headache on one occasion. At no time did the Matron inform me that my wife was complaining of a pain in the chest when she coughed. Neither Nurse Way nor Nurse Adams informed me of such a thing. Dr. Inglis did not refer to it nor did Dr. Goldstein. Cross-examined by Mr. MaysJ\ I was thirty years of age last birthday. I have worked at Port Albert since my wife's death. 1 went there about a week after the funeral. I remained five or six weeks. T worked with a man named Treadwell. I have taken a direct part in instituting this inquiry. I went to visit the Minister of Public Health. That was in Auckland. I do not remember the date. Mrs. Nicol did not go with me. I went alone. Mr. Bradney asked me to go and see him —the Minister. I came back from Port Albert, though not to see the Minister, though I had the intention in my mind. 1 was coming to town for good. I received a letter from the secretary of my union informing me of some rumours that had been going about, and he asked me if they were true. 1 came to Auckland. I wanted to see the secretary of the union. I had it in my mind all the time that my wife had not beer- properly treated. It was my own idea to see the Minister, but I did not know how to go about it. Mrs. Nicol came along and met me as I was coming out of a shop. I had received a letter from the secretary of the union before this. Mrs. Nicol's name was mentioned in the letter. The letter is at home. I can bring it here. The secretary asked me in the letter if the statements were true. I came down to town shortly after. I went and saw the secretary of the union. He told me the union was quite prepared to take the case up if I was prepared to give evidence. I said I would. Several telegrams were sent to Wellington to different members to see if they would grant an inquiry. The reply was that the Minister was coming to Auckland, and he would inquire into all matters concerning this case, and other matters as well. I had in the meantime made a statement to Mrs. Nicol. It was in writing. Mrs. Nicol took it down in her own handwriting from my lips. A full statement. I signed it. I made statements to the Minister. The statement to Mrs. Nicol was the only one that was taken down. I went and saw the Minister. He asked me to state the case to him. I did so as I had done to Mrs. Nicol. I assisted Mrs. Nicol and others to get the Minister to set up this inquiry. I would not dispute that it was the 19th November when I saw the Minister. I had my wife's body embalmed. There were two objects for it. One was so that the body could lie exhumed in case there was an inquiry; the other was that the body had to be taken a long way for burial —to Port Albert. From the burial till the time I came to Auckland five or six weeks later I took no steps to have an inquiry or to bring the matter before the authorities. I did not quite believe that my wife did not recover from her confinement owing to chest trouble. I did not believe it in my own mind. I thought there was something wrong about her treatment in the Hospital. I would have come to town quite apart from the letters I received. I was greatly grieved about my wife's death, and I wanted to stay away from town for a while. That was simply on account of my grief. T spoke to many

H.—3lb.

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[t. chamberlain.

of my friends as to my wife's treatment. I did not go to the Timber-workers' Union of my own initiative. I had conversations with the Matron on two occasions as to the wife's condition. 1 had a conversation with Nurse Broadley. I asked Nurse Way as to the temperature. Before my wife went into the Hospital I used to notice her at night in bed breathe short. I did not tell the Matron that her breathing had been very short at times and she coughed a little now and then. I never asked my wife the cause of the short breathing. I think I mentioned to the Matron and the Sister that 1 blamed my mother-in-law for coming to my house to be nursed, thereby giving my wife too much to do, and that that was the cause of my wife being run down in the evening. I remember Nurse Broadley asking me if my wife had always been healthy. I told her that she was run down of a night, and that 1 thought that was through having too much work. I never referred to an ulcerated leg. I said it was a bad leg. I never used the word " ulcerated." I mentioned that I had noticed my wife's quick breathing to Nurse Broadley. I did not ask her if she could tell me the cause of it. She asked me if she had suffered with a cold before she went into the home, and I told her " No." My wife told me that she thought her mother should not have gone away without seeing her through her confinement. She was rather troubled about this. She never burst into tears about it while I was there. She felt very much hurt that after nursing her mother for this long time she should go away on the eve of the confinement and leave her to herself. I told Nurse Way I was satisfied with the way she had nursed my wife. I have no complaints against Nurse Way. My mother was in my house on one occasion only that I know of while my wife's mother was being attended to there. It is correct that my mother strongly objected to my wife nursing her mother at a stage so near to her own confinement. My mother did not say when leaving for Australia, " Tom, mark my words : you will have trouble through your wife nursing her mother with those bad legs." My mother and my mother-in-law were never on too good terms. I often said at Port Albert that it would only be right if I went down to Auckland and applied to some one to have an inquiry held into my wife's death. I did not say I intended to make a claim for compensation. This was the first confinement in which I had been concerned. On the 25th August the Matron suggested to me that I should go and see Dr. Inglis. I was not told on the night of the death that I had better remain, within reach of a telephone. I told the Hospital authorities they could ring me up at Mr. Smith's, the chemist, or Mr. Norgrove. This was about a week before my wife died. Nurse Adams asked me if I would leave the address, or some place where they could ring me up. I asked them if things were that serious. She said, "No; but you never know when things might be serious." I gave the names I have mentioned. I would not swear this was exactly a week before the death. It was somewhere thereabouts. The nurse told me when I arrived that they had endeavoured to get me for some time on a telephone. I felt in my mind that a message should have been sent to me earlier. Adjourned till 15th instant, at 9.15 a.m. AVednesday, 15th January, 1913. Thomas Chamberlain (cross-examination continued). I produce the letter I have referred to as coming to me from Auckland Timber-workers' Union [Exhibit No. 47]. It is dated the 25th September, 1912. My wife never told me that she had complained to Dr. Inglis about any of the matters I have mentioned here. To Mr. Skelton. ] I never told any one that I intended going for compensation, though several friends came and asked mo if I was going to go for compensation. 1 have always said that I did not know. To Mr. Mays.] I did not, that I remember, talk with any one before the conversation with Dr. Inglis that I have mentioned about the difference between members and non-members of the British Medical Association. The subject has since been the subject of talk. I have spoken to Dr. Makgill about the difference between members and non-members of British Medical Association. Dr. Makgill asked me if I had any complaints about the home. I told him I had. The question of the British Medical Association cropped up then. This was the day after I came down from Port Albert. I spoke to Dr. Brockway on the same subject. That was a few days after Dr. Brockway telephoned to Dr. Inglis. I do not remember any other persons that I spoke to on the subject. If Dr. Inglis says he never mentioned the British Medical Association 1 am prepared to contradict him absolutely. lam so clear that the matter was mentioned by Dr. Inglis that I can swear to it positively. I am sure that Dr. Brockway did not mention the matter to me on the occasion when he telephoned to Dr. Inglis. I was in the dispensary and Dr. Brockway was in the hall when he was telephoning. Dr. Brockway came and told me afterwards what was said between them. I did not myself hear what was said over the telephone. Dr. Brockway fold me he had rung up Dr. Inglis and told him that I wished him (Dr. Brockway) to go along and look at my wife in the home, and that Dr. Inglis informed him the case was not very serious. T say positively that the question of the British Medical Association was not at that time mentioned between Dr. Brockway and me. It is not correct that I heard what was said over the telephone. My evidence on page 22 is not correct on this point. 1 wish to amend it. I say positively now that I did not hear what Dr. Brockway said, but he told me afterwards what was said over the telephone. I did not go back to Dr. Brockway's after the subsequent conversation with Dr. Inglis when the British Medical Association was mentioned. I went a few days later, and saw him, and told him what Dr. Inglis had said. It was on that occasion that the subject of the British Medical Association was mentioned between me and Dr. Brockway. If Mr.' Skelton informed the Court in opening that blood and matter came from my wife's breast when the baby was put to it I suppose it is my mistake. I never went to the trouble to get a record of the number of times Dr. Tnglis saw my wife.

25

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S. FINEB.

Sadie Finer, on her oath, saith. I live at 15 Church Street, Ponsonby, and am a married woman, the wife of Arthur Finer, saddle-manufacturer. I lived next door to the late Mrs. Chamberlain. I was on intimate terms with her for several months. I had opportunities of judging the state of her health before she entered St. Helens. I saw her every day. From my observation she was a strong healthy woman. She had a slight attack of influenza a few months before she went into the home. There was a slight cough with that —nothing to speak of. Influenza made her feel low and depressed, and I asked her if she felt in that condition why she did not see a doctor. She said she had never seen a doctor in her life, and she did not like the idea of going to one. That slight cough then was the only cough I saw on her. That left her a couple of months before she went into the home. I visited her on the eleventh day of her stay at St. Helens Home. [Witness is asked as to her conversation with Mrs. Chamberlain. Mr. May objects. Evidence admitted on same terms as before.] 1 asked Mrs. Chamberlain how she felt. She said she felt all right, but she could not understand why they would not allow her to sit up. She said the confinement was not bad, but she had been torn. She said the Matron had put in a few stitches. I asked here where she had been confined. She said she had been placed upon a board with a macintosh covering, and it was very hard to lie upon. She said she thought that that was where she got a severe chill. She told me that no chloroform was administered to her. She was in a room close to the balcony—l do not know its number. She complained about them using the room as a thoroughfare, as the noise disturbed her. She also told me she did not care for the food at all. She said that her breasts were sore, and they were putting hot fomentations on them. I noticed a few spots on her face —they were festering pimples. I, thought it was strange, as she always had a very clear complexion. I noticed a smell —an unpleasant one. I noticed it when she moved. I visited her once in the isolation ward. There I noticed that she looked rather weak and very I had not noticed the yellowness before. Gross-examined by Mr. Mays.] I did not notice anything about Mrs. Chamberlain's breathing before she went to the home. 1 did not see her at night. I knew she was nursing her mother for some time before she went to St. Helens. The only thing I saw her doing was taking a little food to her mother. That would be in the morning sometimes, and sometimes about midday. I did not see her early in the morning or in the evening. I did not notice her cough when I saw her in the home on the eleventh day. I did not notice her expectorate. I noticed no change in her before she went to the Hospital except that she was depressed and had liver complaint. Ido not think she had lost weight, but it would be hard to tell in her then condition. As to being depressed, she seemed as though she could not stand on her feet. She wanted to lie clown. A woman in her condition would want to do that any way. This continued for about three weeks. I saw her the morning she was admitted to the home. She then seemed very well. She did not complain of anything to me then. She said nothing to me at any time about her mother going away when she was so near her confinement. When I saw Mrs. Chamberlain on the eleventh day she only complained that she could not understand why she was not allowed to sit up. Re-examined by Mr. Skelton.] I disagree with the statement in the case-book that Mrs. Chamberlain had a nasty cough before she was admitted. She had no cough. She had not influenza a fortnight before she was admitted. She complained of the kidney-complaint two months before she was admitted. When I spoke of a liver-complaint before, I made a mistake—l meant a kidney-complaint. Louisa Hunt, on her oath, saith. I reside in Ponsonby Road, Auckland, with my husband, Sydney Clarence Hunt, who is a " Star " agent. I was introduced to Mrs. Chamberlain on the day her mother-in-law left for Sydney. That would be about a week before she entered St. Helens. I visited her there — once in the Hospital proper and two or three times in the isolation ward. I paid my first visit on the day when Mrs. Finer went, but had to come again, as I was rather late, and two were not allowed to see her on the one day. I went next day. [Witness is asked as to their conversation. Mr. Mays objects. Admitted on same terms as before.] I went up the outside steps, and saw Mrs. Chamberlain on the balcony. She was wheeled from the balcony into the little room. She coughed and put her hand to her head. She said the cough made her head ache. She reckoned she got the chill on the board. I said, "What is it like." She said, "They lay you on a table, and you have something to pull." She told me she did not Ike so many people going through her room. She also told me she did not care for the food. She told me on the first day I saw her that the Matron had put some stitches in her and had taken them out, and that the doctor had not seen her for three days after her confinement. I not-'ced a smell. She put her hand to arrange her clothes, and the smell was very bad. I have visited other ladies after their confinement in the same stage as Mrs. Chamberlain was in, but not in the Hospital, but I never noticed such a smell. I noticed that her stomach was very much swollen. I asked her if she had her bandages off. She said, " Yes." I noticed both the bad smell and the distention of the stomach the first day I saw her there. In the isolation ward I noticed that she was very weak and had a longing to get home all the time. She could not understand why she was not allowed to sit up. My last visit was the day before she died, but I would not be sure of this. She was then very weak. I noticed the usual smell. I noticed the same smell as I had noticed on mv first visit. Cross-examined by Mr. Mays.] I only met Mrs. Chamberlain about a week before she went to the home. I had known her mother-in-law before that. It was because I knew Mr. Chamberlain's mother that I visited his wife. There was no talk between me and Mrs. Chamberlain, sen., about Mrs. Chamberlain, jun. I did not know that Mrs. Chamberlain, sen., had protested agains* Mrs. Chamberlain, jun., nursing her own mother so long. When I saw the

4—H. 31b.

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[l. hunt.

patient on my first visit she was entirely covered with the blankets. I noticed that her stomach was distended. Her stomach was so big that I asked her if she had got her binders off. She said they were off. I did not examine her there myself. Re-examined by Mr. Skelton.] As she lay in bed 1 saw that there was something radically wrong, and that her stomach was very much distended. Walter Scott Brockway, on his oath, saith. I am a duly-qualified and registered medical practitioner, practising in Auckland. I knew the late Mrs. Chamberlain. I knew her about three months before her death. I had opportunities of seeing her right up to shortly before she entered St. Helens. On one occasion I prescribed for her for a slight bladder-complaint. That was connected with her state of pregnancy. Apart from that she never made any complaint to me. I should say she was a strong able-bodied woman. She did not complain of nor did I notice any cough or cold about her. On the 19th June last I was called in to attend to her mother, Mrs. Underwood. She was suffering from a varicose ulcer of the leg. I gave her a rest treatment, consisting mainly of elevating the leg and curretting the ulcer. I gave her also a blood-mixture. The wound was not as large as a shilling. The patient made good progress. The wound was completely healed in about three weeks. There was only a mild amount of pus, and that was not of a virulent character. I do not remember when I paid my last visit to Mrs.. Underwood, but I think it was after Mrs. Chamberlain had gone to the Hospital. The wound had been completely healed before that. Mrs. Underwood was capable of doing the very little dressing required to her leg. 1 remember Mr. Chamberlain consulting me with regard to his wife and her want of progress at the Hospital. As a result, I rang up Dr. Inglis. I mentioned to him that Mr. Chamberlain was there, and lie did not seem satisfied with any report lie could get from the Hospital as to his wife's condition, and that he wished me to go up and see her and give him my opinion as as to her condition. I asked Dr. Inglis what were the rules governing the working of the Hospital. He said there was no provision for patients calling in outside attendants, and that the only provision for calling in outside attendance was for the resident surgeon to call in outside surgeons when he deemed it necessary, and that as far as Mrs. Chamberlain's condition "was concerned he said that Mr. Chamberlain had been to his consulting-room on. I think he said, the night previous, and he had explained to him the existence of a tubercular condition as an explanation of the patient's condition at the time. T think that is all the conversation I had with Dr. Inglis on the subject of Mrs. Chamberlain's condition. I understood from what Dr. Inglis told me that I would not be allowed to see Mrs. Chamberlain. I took it as a refusal to allow me to see her. When I prescribed for Mrs. Chamberlain before she went into the home my medicine had the required effect. My observation of Mrs. Chamberlain was then a superficial one. I saw nothing in her to lead me to suspect that there was anything wrong with her or likely to lead to future trouble. I examined her urine before prescribing. There was nothing unusual about it. There was a slight trace of albumen, but on a second examination there was none. I made it clear to Chamberlain that 1. could not see his wife owing to the regulations. Dr. Inglis did not say anything to me about the British Medical Association. Chamberlain kept me posted as well as he could from time to time as to his wife's condition. [Objected to by Mr. Mays.] He said that the only way I could get to see her was to bring her home. He said he was informed at the home that he could bring her home, but he must assume the responsibility of doing so. I advised him that it was foolhardy to do so and that she had better be left there. No further attempt was made by me to see her.] Cross-examined by Mr. Mays.] Where there is pus there necessarily is sepsis to a degree, the degree depending on the virulency .and the character of the pus. The ulcer had pus in it. I do not think it was the pus that would cause septicaemia in a pregnant woman. The pus was septic. I admit that a tubercular condition of the che«t may be more or less dormant or latent for some time without showing any manifest signs. I admit that childbirth, and specially the. birth of a first child, may cause an aggravation of that condition and its development. That forms a very serious problem of medicine to-day. Ido not know as a fact that Mrs. Chamberlain dressed the ulcer on her mother's leg. I (lid not see her do so. No one told me that Mrs. Chamberlain, dressed the leg. It. would be possible and likely from Mrs. Underwood's condition that she would dress the wound herself. At the times T was there Mrs. Chamberlain was never in the room. The wound was quite accessible to Mrs. Underwood for dressing by her. I did not approach Dr. Inglis witli the view in my mind of consulting with him professionally. I thought he would not do so. That is because he is a member of the British Medical Association and lam not, and members will not, as a rule, consult with those who are not. He did not give it to me as a reason. I did not seek a consultation with Dr. Inglis because it was in my mind that he would not consult with me, as I am not a member of the British Medical Association. I did not, to him, suggest a consultation. I thought it was useless, and dicl not want to put myself or him in an embarrassing position. I have been refused a consultation on one occasion on the ground that I was not a member of the British Medical Association, and I thought it was a general rule, and for that reason T did not care to suggest a consultation with Dr. Inglis. T was anxious to relieve Chamberlain's anxiety by any legitimate means I could. I have never been faced with the position of disagreeing with or not having confidence in the consultant. T never suggested that I should go on merely a friendly basis. I should consider that a most unprofessional thing to do. My impression now is that Dr. Inglis told me the case was tubercular. I do not think he told me anything else. I would not be sure whether or not Dr. Inglis told me then that Dr. Goldstein had examined Mrs. Chamberlain's lungs. Our* conversation did not exceed five minutes. I was of opinion that Chamberlain's best course was to leave his wife in the institution. I had only hearsay as to the woman's condition, and I could give no opinion in any way as to Dr. Tnglis's ability to deal with it, I did, at some time later than the telephone

W. S. BROCKWAY.]

27

H.—3lb.

incident, discuss the matter of the British Medical Association with Chamberlain. Mrs. Chamberlain never complained to me of being run down. She seemed in buoyant spirits when I was there, except for the bladder trouble. She gave me no cause to suspect that she was suffering from any lung trouble. I do not think anything 1 have done can be construed as taking part in setting up this inquiry. I have answered questions that have been asked me. Chamberlain brought me the death certificate to look at. He wanted to know what septicaemia was. I told him. I think he asked me on one of his visits if there was any way in which I. could be got to see his wife. I told him I did not know—that he had better consult the legal authorities. I think I considered an inquiry was desirable after Mrs. Chamberlain's death. I think that what I did would be termed "encouragement" towards the holding of an inquiry. For some time I have considered an inquiry desirable. I do not think I furnished any statement, but I tabulated a synopsis. Some one came to me—l think it was Mrs. Nicol—and showed me a letter from the Minister, or some one at Wellington. I. gave some assistance in showing how they should jaroceed. Re-examined by Mr. Skelton.] I had some experience in a lying-in hospital at Lees, in Chicago, United States of America. I was employed in the institution as an honorary physician. I was studying obstetrics at the time, It was part of the course in obstetrics. There every patient was treated as a septic patient and was given an antiseptic bath. This was a precautionary measure taken in every case. Had this been done in Mrs. Chamberlain's case it would be possible, but improbable, for her to incur septicaemia. It is difficult to say the length of time infection will break out. I would not expect that a patient would be septic from germs from her own home after the time that elapsed in this case, especially as the pus in the case was not septic to any degree. There were no septic outbreaks while I was in the institution I have mentioned. It is impossible not to have a septic outbreak at some time. Adjourned till 16th instant, at 2.15 p.m. Thursday, 16th January, 1913. [Dr. Bamford announces that Mrs. Nicol desires to withdraw charges Nos. 3 and. 4: As to charge No. 1, Mr. Mays makes admissions in writing which are put in by consent [Exhibit No. 70]. Dr. Bamford says he is prepared to leave the matter at this, with right reserved to call expert evidence if need be in rebuttal of any explanation offered by Mr. Mays.] Mrs. Nieol's Charges—No. 2. Frances Williams, on her oath, saith. I am the wife of John Williams, timber-worker, of Auckland. I am sister of Laetitia Marsh, now deceased. I know that she was admitted [to St. Helen Hospital [on the Ist July, 1910, and that her child was born there on 2nd July, 1910. I first visited the Hospital in connection with|my sister on the Wednesday after the child was born ; that would be about five days after the birth. I went for the purpose of seeing the patient. The Matron told me that I could not see Mrs. Marsh, as she had scarlet-fever. I was alone. I said, " Well, this is a strange place to come to get scarletfever." The Matron said, " She did not get it here. She came from the country, and they had fever at home, and she brought it in with her." I said " Oh, no ; she came here all right. She was nine weeks at a boardinghouse in Grey Street." I said she was all right, and she did not bring the fever there. I said I was at my sister's when she received a letter from Mrs. Barry, the boardinghouse-keeper, saying that she had left there cheerfully and everything was going on all right. I think this letter was burnt. The Matron then said to me, " Are you her sister ?" I said "Yes." I repeated that this was a strange place to get scarlet-fever. The Matron said that she had gone up to Dr. Florence Keller's, and she must have got it while she was waiting in the surgery. I understood the Matron to mean, though I am not sure of this, that my sister had been to Dr. Keller's on the same day as she was admitted to the Hospital. I did not see my sister at the Hospital on this occasion. The Matron promised to tell my sister that I had called. I told her that I felt quite upset at the news. The Matron told me there was nothing to be alarmed about —that it was a very mild case. She said, "We must isolate her on account of the other patients." Something was said about her going to the Auckland Hospital. I left then, and went over to Mrs. Barry's. I went next to the Hospital on the followingSaturday. I was summoned by a note which came forme. I met my sister, Mrs. Hooker, as I was on the way there. We met in a car. She was going to the same place. I met other members of the family at the Hospital. I saw the Matron. I asked her where was my sister. She asked me if I wanted to see her. I said, " Yes ; that is what we came for." She said, " You can't see her. She is peeling." I said, " She can't be peeling so soon. Is it scarlet ?" She said, " Oh, yes ; the doctor says it is scarlet." I said, " I want to see my sister. She might have something to say to us. I must see her." The Matron said, " Have you any children at home." I said, " Yes ; but I don't mind. I will do anything to see my sister, and will put up with the consequence." The Matron said, "If you go in you must not touch her or go near her. You must put white gowns on, and two can go in at a time." My sister Mrs. Hooker and I put white gowns on, and went to the isolation ward to see Mrs. Marsh. She looked very bad. Her eyes were sunk and glassy. She tried to speak, but we could not understand the broken words she uttered. Her jaws were set. In a little while we thought she said, " I'm dying." That was in broken words, and took a long time. I looked at her closely. She was looking very black. I could see no signs of peeling. I turned her nightdress down at the back of her neck. She looked very black, and. I could see no signs of peeling. The nurse called me away. I was told by the nurse not to touch her. I remained for some time till I heard some one say that they thought her husband had come. Before I left the Hospital. I was told that my sister was dead. I cannot say how long it was after I went there that my sister died.

H.—3lb.

28

[p. WILLIAMS.

Examined by Mr. Mays.] My sister lived at Riverhead. She never complained to me that her heart was troubling her. I remember that there was ( a good deal of scarlet-fever about in June and July, 1910. My sister told me she had been at Mrs. Barry's for nine weeks. I know a great deal about scarlet-fever. I have nursed a lot of it. I know that some days must elapse between infection and the rash showing. I was never told that the scarlet-fever rash showed on the second day of the confinement. My sister was about thirty-eight at the time of her death. This was her sixth confinement. I complained to my friends that I was not allowed to see my sister soon enough before her death. 1 did not know how to go about making complaints to the Hospital authorities. My husband is not a member of the Timber-workers' Union. Had I known how to go about making a complaint I would have done so. Minnie Hooker, on her oath, saith. lam a married woman and my husband is a bookbinder in Wyndham Street. lam a sister to the late Mrs. Marsh. I know that she went to St. Helens Hospital. I heard through the doctors of the birth of her child. The birth was on the 2nd July, and I heard of it on Monday, the 4th July. On Wednesday, the 6th July, I had a conversation with the last witness. I went on the Friday afternoon about 4 p.m. to the Hospital to see my sister. I saw the Matron. I asked her if I could see my sister, She said, " You can't see her ; she has got a mild form of scarlet-fever." I asked her how she seemed. She replied, " Very (or fairly) well, but that it was a mild form and there was nothing to be alarmed about." I asked her if my sister was conscious. She said,'" Oh, yes ; I saw her this morning. I could not go into the room ; I had to keep myself pure for the other patients. I saw her through a window." I asked if my sister was worrying over her children. She said, "Oh no." I asked her if she would like to.see her baby, and she said she " Couldn't be bothered." She said further, "We will have to send her to the public Hospital. We have no room here for her." I said, " Will you tell my sister that I will take her baby, and that will enable her to get better quicker if she knows I have it." The Matron said that my sister would be better in a fortnight, but she would not be out of the home for six weeks. I left without seeing my sister. On the next day —the Saturday afternoon —I received a telegram to come at once to see my sister. I met my sister Mrs. Williams on the way, and we went together. I have heard her evidence to-day. It is quite a correct description of what took place. I saw the discoloration on my sister. I was the first one to touch her. I went to her and shook her, and tried to make her speak. She was lying on her right side, huddled up in the bed, breathing very heavily. I bent over her, and saw that one eye had gone almost into the socket, and she was quite black. Her hands had gone away, and she had gone very thin. Her hands and nails were quite black. I could not get anything intelligible from her. She seemed to know my voice. She tiied to tell me she was dying. I went to see the- Matron after leaving my sister. I told her that it seemed terrible to see my sister like that, and that I would like another doctor. She said it would be no use bringing another doctor, as he could not be here in time. She said, "If you wish it I will ring up, but it is no good." While I was still talking to the Matron my brother-in-iaw and sisters came to say that the patient was gone. It was after 4 when we got to the Hospital, and it must have been about 5 when she died. We could not have been there more than twenty minutes or a little over. Examined by Mr. Mays.] I saw my sister every two or three weeks. She used to come to town. She never complained of her heart. She complained only of a slight pain in her left side—due to overwork. She worked very hard. The pain was down below the waist. Ido not know that at that time there was a good deal of scarlet-fever about. I did nothing to bring the subject before the authorities. We were not satisfied with the way my sister died and the way we were kept from her. I heard that this inquiry was coming on. Mrs. Nicol sent a message for me to go and see her. I went and saw her, and gave her an outline of my evidence. Florence Keller, on her oath, saith. I am a duly-qualified and registered medical practitioner, practising in Auckland. I knew the late Mrs. Marsh. I remember her admission to St. Helens Hospital. She came in to see me on the night before her admission. I had been attending her for about a year and a half before that. I never during that time treated her for her heart. She came to me on the night before her admission, and wanted to know if she was ever going to be confined. She was very tired waiting. She was in good spirits. Stevenson gives the period of incubation for scarlet-fever as from two to ten days. The first symptoms are chilliness and sore throat. It is quite possible that Mrs. Marsh developed scarletfever on the second day after she entered the Hospital. The peeling commences in from ten days to two weeks, depending on the virulence of the case. Examined by Mr. Mays.] I had last seen Mrs. Marsh prior tojthe Thursday, 30th June—about three weeks before that. I knew she was boarding somewhere, but I did not know where. Scarletfever may be picked up almost anywhere. Sudden heart-failure may accompany any acute fever, whether the patient has had previous heart trouble or not. It is more likely to accompany the fever if the patent had had some heart trouble previously. There was some scarlet-fever about at that time. [As to questions arising under suggestions 5, 6, 7, 8, and 9, Dr. Bamford states that he cannot at present call any evidence, and they are for the present deferred.] Adjourned to 17th January, at 2.15 p.m. Friday, 17th January, 1913. Kate Annie Underwood, on her oath, saith. lam wife of George Robinson Underwood, farmer, of Port Albert, Kaipara. lam mother of the late Mrs. Laura Elizabeth Chamberlain. My daughter was of strong physique. Up to her death her health was very good. She had had no illness at any time before her death. For some time she lived

29

H.—3lb.

K. A. UNDEBWOOD.j

away from home. She was in service in Auckland. That was for about four years. On"the 17th June of last year I came down to Auckland from Port Albert. I came for treatment for varicose veins. 1 went straight to my daughter's residence, and remained there till I returned to Port Albert, which 1 did on the Bth August. I noticed nothing wrong with my daughter's health during my stay in Auckland. I was attended by Dr. Brockway. Two days after my arrival in Auckland he performed a slight operation on one of the veins of my leg. He required me to rest and keep the leg up. I saw the wound. It was about an inch in length. It remained open about a week or ten days. Dr. Brockway would not let me get up under a month. Dr. Brockway dressed the wound first. After that I dressed it myself. At no time did my daughter touch or dress the wound. She wrung out a few hot flannels, and gave me them to put on myself. I put on the hot flannels only for about twentyfour hours —that was, just in the daytime. The hot flannels were discontinued on the second day. From that time on I did the dressing myself, except when the doctor came in, and then he did it. I returned to Port Albert on the Bth August. Later, from a communication I received, I came back to Auckland and visited my daughter at St. Helens Hospital. That was three weeks to the day after I arrived home. I found her in the isolation ward. [Mr. Mays objects to questions as to what passed between witness and her daughter. Admitted on same terms as before.] My daughter told me that when the baby was born she laid on the table until she shivered. She said she also shivered when she got into her bed. She said it was just a table with a piece of waterproof cloth and a blanket. She told me, further, that the Matron had put some stitches in her, and that after they had been in a day or two they began to throb, and the Matron took them out. She told me, too, that the doctor had not seen her for three days. She told me that when they brought her down to the isolation ward the shaking was more than she could stand. I noticed that she had a very bad smell with her, and that her stomach was very much swollen. I noticed the smell as soon as I went in. I asked my daughter if she had got her bandages off when I noticed the state of her stomach. She said, " Yes." I asked her how it was that her stomach was like that, and she said she did not know. I saw the bedclothes removed from her just slightly at certain times. I then noticed the distension of the stomach. I went to see my daughter every day for eleven days. My daughter told me she could not eat the food the way it was cooked. She said she would like to be home. My daughter also told me that when on the table she was wet up to her shoulders. She did not say how long she was allowed to lie like that. I have just heard you read the extracts from the case-book. It is quite false that my daughter dressed my leg night and morning for several weeks. It is quite untrue that she had a nasty cough, and had influenza a fortnight before admission. Apart from the usual matters connected with pregnancy, my daughter had nothing wrong with her. She was in the best of health. Examined by Mr. Mays.] My leg was bad two days before I got here. I have had varicose veins for some years. The vein had not burst before I came to town. The doctor lanced it in one place. A little pus came out when the doctor lanced it. He took it out, and no more came out afterwards. I remained in bed for the whole of the month. This entailed no extra work on my daughter. I had another child there, who waited on me. My daughter did the washing for me. She was not more run down of an evening than you would expect with a woman in her condition. She never used to grumble. She told me at the home that the Matron used to go in and not speak to her, and treat her as if she was of no consequence—both the Matron and the doctor. She did not tell me that she complained to the doctor about the stitches. She said nothing about the state of her breast or the milk. She said they had taken the baby away from her, but she did not know for why. She said nothing when I came back the second time about my going away so soon the first time. She knew that I had to get back to attend to my family. I knew she had some little urinary trouble such as most women have at that time. I never spoke to the matron or the nurses of any complaint of my daughter, nor did I call on the doctor. I never made any move in the matter till I was summoned here as a witness. To the Commissioner.] I had some lotion andjfpowder to put on my leg every two or three hours. There were no bandages till I got up. I had to cover the stuff I put on with pieces of rag. These were burnt. My daughter would not touch them. I used to wrap them up in paper, and give them to her to burn. She never handled or washed them in any way. I recognized that there was risk. I received no letter from my daughter after leaving Auckland. She went into the home shortly after I left. I got a letter from her husband telling me of the birth. The first I heard of the complaints was from my daughter herself. Mrs. Hunt and Mrs. Finer afterwards told me what my daughter had told them. Adjourned to the IBth January, at 10 a.m. Saturday, 18th January, 1912. Dr. Bamford announces that he desires to withdraw from the case, and that he does so at the request of Mrs. Nicol. Leave given him to retire. Mrs. Nicol announces that she will conduct her own case, and asks for a return of cases transferred from St. Helens Hospital to the General Hospital during the last two years.] Adjourned to the 20th January, at 10 a.m. Monday, 20th January, 1913. [Mrs. Nicol hands in further complaints re Mrs. Allen. Mr. Skelton not in attendance. Agreed that evidence-in-chief be taken on these last complaints, and that cross-examination be postponed.]

H.—3lb.

30

[A. ALLEN.

Angelina Allen, on her oath, saith. 1 am the wife of George Allen, mill-hand, of Union Street, Auckland. I was admitted to .St. Helens Hospital on the 22nd November, 1911, for my first confinement. The Matron asked me for my application fee of £1 in full. She did not tell me that I could pay it by instalments. The b..by was born the next day. On this occasion I was satisfied with my treatment. I was torn dm ing confinement. I was attended during confinement by the Matron and two nurses. I did not see a doctor at all during that time. I was discharged on the fourteenth day. The baby was fragile at birth, and it died at the General Hospital, where I took it when it was four months old. It suffered from gastritis. I was admitted to the Hospital for my second confinement on the 31st October, 1912. The Matron confined me. I was quite satisfied with the confinement. I did not get on quite so well. I was transferred from one room to another on the eighth day. The following day I took a chill, and 'my breasts were sore. I was nursing the baby this time. It was healthy when born. I did not understand that I was suffering from abscess of the breast. Fomentations were applied to my breast. I asked the nurse every time what she thought it was, and she said that I had just caught a slight chill. I nursed the baby for three weeks. There were two other patients with me in the second room. Both had bad breasts. I was not satisfied with the baby's condition when I was discharged from St. Helens. I was discharged on the fifteenth day. When I took the baby away it had diarrhoea, and her buttocks were almost raw. The motions were green. I was not seen by a doctor at all during this confinement. The green motions continued after we left St. Helens. A rash which at that time had been confined to the buttocks and legs spread all over the body. After two or three days 1 took the child back to St. Helens for the Matron to see and advise me. The Matron told me to take the child to a chemist. I did so —to Mr. Eccles, Hobson Street. He gave me some medicine. After a few days I took it to Dr. Owen. He prescribed for it. As it got no better, I called in Dr. Porter. That was two days after I saw Dr. Owen. He advised me to take it to the General Hospital. I took it there the same night. It was there five weeks when it died. [Mrs. Nicol draws attention to Rule No. 21 of the Rules for the Management of State Maternity Hospitals. Mr. Mays draws attention to Rule No. 13.] To the Commissioner.] I did not suggest to the Matron that my infant might remain in the home for treatment. I did not know that I could leave the child in the home if it were considered necessary. There is no copy of the Act or rules posted in any of the wards that I know of. This was my second child. My first child died in the General Hospital. This was a delicate child when I left the home. It remained with me for three months, when it was taken to the General Hospital. It was once in that time attended by Dr. Brockway. He advised me to take it to the General Hospital. I took it there at once. It remained there five weeks, when it died. I was seventeen years of age when I was married. Before my marriage I had no experience whatever of the care and treatment of children. I knew how they should be fed. I knew of the different kinds of food an infant should get. I fed the first child at the breast till it was two months old. After that it was fed on barley-water and milk till it went to the Hospital —that was about a month. The child was pretty well wasted by the time it was taken to the Hospital. As to the second child, it was fed at the breast till I left the Hospital and afterwards till it was three weeks old. At that time it went to the Hospital. Till then it got nothing but the breast. I knew nothing of the Plunket nurses. I got no advice from any one but the doctors and chemist. (Cross-examination deferred till 10 a.m. to-morrow. (See post, p. 36). Examination-in-chief continued.] I was torn during the first confinement. The Matron put in some stitches—one, two, or three. [Mrs. Nicol announces that this is the only witness she intends to call on this complaint.] [Mr. Mays says he will now call evidence touching the charges relating to Mrs. Marsh and Mrs. Porch.] Maeion Bowry, on her oath, saith. I am a boardinghouse-keeper carrying on business in Grey Street, Auckland. I remember Mrs. Laetitia Marsh staying with me for some weeks in 1910. She used to complain of the stairs and of palpitation. She used either that word or some word such as " suffocation." She was close to confinement. Examined by Mrs. Nicol.] My house is situated at the end of a flight of steps downwards ; I do not know the number. It would be about fifteen. When Mrs. Marsh was at my place the steps were not so level as they are now. Mrs. Marsh seldom went out. I do not remember writing a letter to Mrs. Marsh's relatives saying that she went out of my house to St. Helens cheerfully, waving her hand as she went. I do not even remember writing a post-card. There was no scarlet-fever in my house while she was there. There was no person in my house ill when she was there. Apart from her pregnancy, I do not remember anything to raise any suspicions in me as to her health. I expected that she would pass through her confinement without serious trouble. There are stairs in my house leading from the bedroom to the kitchen. Mrs. Marsh used to go up and down these. Tracy Russell Ing-lis, on his oath, saith. I am a duly-qualified and registered medical practitioner carrying on practice in Auckland. I am also Medical Officer to St. Helens Hospital, and have been such from the foundation of the Hospital. I was appointed by telegram from Mr. Seddon. I was asked if I would accept it, and I did so. As to the time, it was a little before Mr. Seddon's death. I have not got the correspondence relating to my appointment. I did not bother to keep it. It may be amongst my papers at home. It may be destroyed. I was appointed as from the 1st June, 1906. I was the first Medical Officer appointed. To start with, the honorarium was £50 per year. This was increased afterwards —I cannot say when —to £100. The original agreement with Mr. Seddon was that the honorarium should

T. R. INGLIS.]

31

H.—Blb.

be increased to £100 once the Hospital was properly started. There was no written agreement. There was nothing but a telegram. I got it from Mr. Seddon, asking me if I would be prepared to take the appointment at St. Helens. I wired asking for the conditions. I got a reply telling me part of the duties, and saying that he (Mr. Seddon) would see me when he came to Auckland. I saw him in Auckland. He told me what he wanted me to do in regard to St. Helens, which had not at this time been opened. He gave me verbally a sketch of my duties. He told me that the rules would be drawn out later —a printed set of rules, which we have since received—two lots. I agreed to a remuneration of £50 at the start, and I had his word that when the home was properly started—he said it was more or less an experiment starting the homes —and that when they were properly established my honorarium would be increased to £100. This interview took place six months, I should think, before the home was opened. St. Helens was opened on the Ist June, 1906. When I accepted the appointment there was nothing in writing setting out the duties I was expected to perform. There was no letter of appointment defining my duties. When I commenced my duties on the Ist June, 1906, I do not think I had any written instructions with regard to my duties. I had verbal instructions from Mr. Seddon and the Inpsector of Hospitals. From them I had instructions that I was to attend all confinements at St. Helens that required medical assistance, in the opinion of the Matron ; that I was to visit the home at such other periods as I thought fit, and at any time when the Matron required me ; that I was to deliver a course of lectures to the nurses twice a year ; that the medical administration of the Hospital was under my sole care, and that the Matron would report to me as occasion demanded ; that I was to attend district cases (outside cases) if the Matron or sub-matron required assistance ; that I was to approve by initialling the application form of all applicants to St. Helens. Mr. Seddon also instructed me as to what patients were to be admitted. Mr. Seddon told me that the home was intended for the wives of workers and country patients who could not be looked after properly in their own homes. I asked him for a guide as to the wages of applicants' husbands, and he told me from £2 to £2 10s. or £2 15s. a week, and to use my judgment with regard to the size of the family. I had to approve of the admissions to the home. This did not apply to cases of urgency. I cannot say if there were instructions as to urgent cases, though I think the point was discussed. Another point was that single girls were not to be admitted, but that we could attend them as out-patients. I made notes of these verbal instructions at the time. I have not got these notes. I destroyed them with a lot of old papers about two years ago. We had the rules then, and I did not think they would be needed any more. I was supplied with a copy of the Midwives Act and the gazetted regulations of the 27th April, 1905. I considered that my duties were regulated by the verbal instruction I had received and the regulations. I considered Regulation 9 contained one of my duties—that was, to deliver lectures. The verbal instructions I received were more elaborate than the printed ones. I considered the verbal instructions elaborated the printed rules, though I did not get the latter till later. I have given more lectures than required by the regulations. I have kept a record which I can produce of my work in connection with the Hospital. I received verbal reports from time to time from the Matron. I received no formal or official reports from her. I received a copy of rules [produced —Exhibit No. 65]. They bear the printer's imprint of 1905. They are called " Rules for St. Helens Hospitals." In 1911 I got fresh rules. I was not told that they would supersede the earlier ones. I naturally took it that they would. These are the only rules and regulations I have received. I have had a memorandum from the Department occasionally. Were I called in by the Matron to attend a case in the Hospital which was abnormal, or required the administration of an anaesthetic, I would attend and visit the patient as I would a private patient of my own motion if I thought she required it. If a patient went along all right and then developed symptoms indicating some trouble I certainly would think it my duty to attend such a case. I would attend and keep on attending such a case as long as it required me. I did not keep a case-book in the Hospital. One was kept there. It does not show the daily condition of the patient. In a general or mental hospital a case-book should be kept showing the state of each patient daily, if necessary. No case-book was kept like that here. Temperature-charts were kept. Examdnation-in-chief continued. —l remember seeing Mrs. Marsh in the Hospital. I keep what I call a day-book of my attendances. I keep no record separate from that of my own patients. I make an annual report to the Department. I suppose I saw Mrs. Marsh the day she was confined. I have no record except my memory. I have no record of the names of the patients I saw every day. I only saw Mrs. Marsh on a certain day, because I saw every patient on the days I was there. I do not remember if I was called specially. I now say that I think I was called specially. I think the Matron told me she was developing a rash. I saw Mrs. Marsh, and found her to be suffering from scarlet-fever. She was in one of the ordinary rooms —I cannot now say which. I had Mrs. Marsh isolated, and reported the case to the Health Department. I produce my notification and my covering letter. [Exhibit No. 49.] It is dated the sth July. I think I saw the patient before that. As far as I remember, she was moved to the isolation ward the day I saw her. I produce the reply I got from the Health Department. [Exhibit No. 48.] There was a tremendous lot of scarlet-fever at that time. The patient died on the 9th July. That day she developed a sudden attack of heart-failure. A chart of her temperature was kept. I saw the patient every day. The nurse in charge kept the chart. [Mr. Mays says it was destroyed, because it was kept ward in which was a scarlet-fever patient.] She showed signs of heart-falure within twenty -four Tiours of her death. The final attack was sudden and without warning. If the patient showed a rash within forty-eight hours of her admission I would say she was infected outside. The period of infection is four to twenty days, with an average of ten. That is according to Dr. Ostler, an authority on the subject. Pgave'instructions to. the' Matron to send word to the relatives'as soon*as it seemed'clear'to me as to her'actual state. It*is a'rule to admit relatives to a ward where patients are suffering from infectious diseases only when we do not think the patient will recover. While there is a chance of recovery, we admit no one but the Hospital staff. The patient's attack of scarlet-fever was mild, though scarlet-fever is always serious in a confinement

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case. I have heard the evidence of Mrs. Marsh's sister as to the pain in her left side, and the evidence ' of Mrs. Bowry as to Mrs. Marsh's palpitation. I think those two facts would render the patient more liable to attacks of the heart. Nothing more could have been done to save the life of Mrs. Marsh than was done. Hers is the class of case that one may meet with at any time in any maternity hospital. We cannot always foresee a sudden attack of heart-failure. So far as I can judge, the relatives of this patient could not safely have been admitted to see the patient earlier. To the Commissioner.] I first saw the rash on the second day after the confinement. Examined by Mrs. Nicol.] It is not my duty to see every patient who goes into the Hospital. It lies with my own judgment whether, when I go to see an abnormal case, I go and see all the other cases in the Hospital. I can do so or not, as I like. I always ask the Matron if there are other cases in the Hospital requiring my attention. Ido not think I was there at Mrs. Marsh's confinement. lam in charge of the Hospital. With regard to the medical administration, I can overrule the Matron, though I can hardly be held responsible for the mistakes of my subordinates. Igo round the Hospital and see all the patients on my visits. lam in charge of the medical part. The Matron is in charge of the domestic part and of the nurses. I consider lam responsible for the health of all the patients, whether lam called in or not. That is the position I have always taken up. If a patient were sutured by the Matron I would not say it was necessarily her duty to call me in. It depends on the suture. It is the custom in every maternity hospital I know of in New Zealand for the Matrons to insert the sutures in tears of the perinseum of the first degree. I know of some Matrons of outside institutions who carry out this duty. I have seen the duty carried out in Melbourne. There is nothing relating to the matter in the rules of St. Helens. It is certainly not a fact that pregnant women are almost invulnerable to scarlet-fever. It is the thing we fear most. I do not know Dr. Barrett's work on " Domestic Medicine." There were no other cases of scarlet-fever in the home when Mrs. Marsh was there. The contagion in scarlet-fever begins when the rash breaks out, or before that. I believe a patient is infectious almost right from the period of incubation. The patient is generally worse just before the rash appears. The period of incubation is from four to twenty days, averaging ten days. It is quite possible in a mild case of scarlet-fever that the patient might be cheerful and bright, and without any running of the nose on the day before the appearance of the rash. I think there was danger to the relatives being admitted to see the patient before they were. Infection is not limited to the peeling. I think it was dangerous to admit the husband, but there must have been some special reason for it. The rash is a certain symptom of scarlet-fever. There are other prior symptoms — sore throat, pain in the hack, a catarrhal condition of the nose. When Mrs. Marsh was seen by me when she had the rash she told me she had a sore throat. Ido not think I had seen her before she was confined. Ido not see patients before they are confined unless there is a special reason. It is not my opinion that the contagion is mostly due to peeling. The time from the rash to peeling depends on the severity of the attack. Had the patient the rash on the Sunday she could peel on the next Thursday or the Friday. Heart-failure might account for what I think was meant by the witnesses when they spoke of black patches. Heart-failure is also one of the results of septicaemia. The jaws being set is a sign of approaching death. There used to be an idea that scarlet-fever produced septicaemia. That is not now held. What was taken to be septicaemia is now taken to be a virulent form of scarlet-fever. Mrs. Marsh was isolated as soon as I was satisfied that there was scarlet-fever. I cannot now say when I suspected scarlet-fever. I cannot now say how long the patient remained in the room with the rash on her. I cannot say how long the patient had the rash on her before she was isolated. It is absolutely untrue that I informed Mr. Hooker that if the Matron said, to his sister-in-law that it was only a mild case of scarlet-fever the Matron ought not to have said it, as her case was hopeless. I say that the case of scarlet-fever was a mild one. I never told any one that the Matron was wrong in saying that it was a mild case of scarlet-fever, and the patient would be up in a fortnight. I never told any one that the Matron was wrong in anything she said. Ido not remember saying to any one that I had put on a special nurse. There was a special nurse on all the time. That was because it was a case of scarlet-fever, and the patient was isolated. To the Commissioner. —l swear positively as a medical man that in my opinion Mrs. Marsh died of scarlet-fever and heart-failure, and nothing else. I also swear that I gave the case all the attention and medical skill it demanded. I swear that the patient was properly treated throughout her illness. I know of nothing that was done or left undone that in any way contributed to the patient's death. The isolation ward in which the patient was placed was a suitable isolation ward as regards herself. It was all right that the ward should be used for other patients after thorough disinfection. It was made for disinfection. After thorough disinfection it would be quite safe to put another patient in that ward. Examination by Mrs. Nicol continued.] I could not say when I saw the symptoms of heart-failure. There were symptoms of heart trouble a day or so before the death—perhaps two days. I cannot fix it more definitely than that. The heart-failure killed the patient. Ido not at this time remember what the death certificate said. I gave the certificate. I have a record of it. Had the patient's condition at 9 a.m. on the date of death warranted it, the relatives might have been admitted then as well as twenty minutes before her death. When we considered death to be imminent we sent for the relatives. That was on the day she died. In my opinion, there was no necessity for alarm till the day the patient died. When the symptoms of heart-failure occurred it became a complicated case. When the symptoms of heart-failure appeared I still thought Mrs. Marsh would get over it. I did not call in a consultant, because when the case showed itself to be hopeless there was no chance and no necessity for a consultation. Re-examined.] Mrs. Marsh died just when the relatives were discussing the matter of calling in another doctor. So far as I know, the Matron sent for the relatives at once. I have an idea, but I am.not sure, that it was in the evening when I first heard of the rash. I know of no cases where the Matron has failed to report symptoms which. I ought to know.- All symptoms are reported promptly

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by her. I can think of no better system of reporting than we have now. I have had thirteen years hospital experience. At the present time the great bulk of my practice consists of obstetric and gynecological work. Looking at Mrs. Marsh's case from the standpoint of to-day, I know of nothing that could have been done for her better than we did. Cross-examination continued.] I saw Mrs. Marsh on the day she died. The sunken and glassy eyes and the weakness could have come on during that day. On the day of the death I was specially called in. To the Commissioner.] I can give you my attendances, but I cannot give you what I did or saw on the various days. Ido not know if my appointment was gazetted. Re-examination continued.] I know that books similar to that now produced are kept in the Hospital since its establishment. [Exhibit No. 30.] It is called the " Nurses Daily Report-book." This is the only one now in existence except the one now in actual use. The earlier ones have been destroyed. The case-books are written up from these books. To the Commissioner.] When necessary I examined the nurses report-books —I know that the earlier report-books are destroyed on their completion when their contents have been entered into the case-books. That is the custom. Ido not think these report-books would be of any use except in the case of an inquiry. I think such records are destroyed at the Auckland Hospital. I have frequently had occasion to call in another practitioner to consult with me in regard to cases in this Hospital. In these cases the consultant has always been nominated by me. I have called in so many different men that I cannot remember their names. Were I asked by the husband of a patient who was very bad if I would consent to another medical man being called in I would certainly consent. If the husband named a practitioner I would claim to exercise my right to refuse to consult with him. I would not refuse merely because the medical man mentioned was not a member of the British Medical Association. I have not known a consultation to be refused in Auckland solely on the ground that the medical man mentioned was not a member of the British Medical Association. That alone would not be a sufficient reason to refuse a consultation. A valid objection would be that I did not value the opinion of the medical man suggested as a consultant. Assuming that I had no faith in the suggested medical man's opinion, I would refuse a formal consultation, but I would allow him to see the patient. Were I then asked to permit this medical man to attend the patient I would refuse, because I have no power to do so. In private practice, if the people had no confidence in me I would turn the case over straight. I would not consult with any man I had not confidence in. If the husband of a woman asked for leave to bring in another man, I say I have no power to let another man in. If I called in a man as consultant being a man in whom I had confidence, and he differed from me in his treatment, I would follow his treatment. That is why I have to be careful in calling in a consultant. If under Rule 22 I called in a consultant, and he differed from me as to the treatment of the patient, I would probably call in a second consultant. If he agreed with the first consultant, I would carry out the treatment. I would have to do this in a public position. I would not do it in private practice. In the case of a private patient, if the patient or relatives desired that the treatment should be that of the consultant I would retire from the case, and leave the patient in the consultant's hands. In Mrs. Marsh's case her sudden collapse was quite unexpected. Tracy Russell Inglis, recalled, saith. I have now heard the evidence of witness Mr. Hooker (see below). I have no recollection of saying what he attributes to me. I did not say that I knew Mrs. Marsh was in a dangerous or critical position the day before she died. James White Hooker, on his oath, saith. I am a bookbinder. I saw Dr. Inglis with regard to Mrs. Marsh on the evening of her death. I went with Mr. Marsh, who is my brother-in-law, to see Dr. Inglis, to ascertain the cause of death and get a death certificate. I cannot give the exact words he used, but the real gist of the thing was this. We asked the cause of death. Dr. Inglis stated that it was scarlet-fever. I stated that my wife had been there the previous day, and the nurse had stated it was a very mild form, and there was no need for uneasiness. Dr. Inglis said, " She should not have said so, because I knew the previous day that she would die, or she was in a critical condition," one or the other of these statements, I am not sure which. Mr. Marsh was present and heard this. I have no idea where Mr. Marsh now is, and I have not seen him for about six months. Heart-failure was not mentioned by Dr. Inglis. Cross-examined.] Heart-failure was never given by Dr. Inglis as the cause of death. Mr. Marsh was-talking as well as I was. Dr. Inglis was talking sometimes to me and sometimes to Mr. Marsh. I have no grievance on the score that I was not told. I attach no blame to Dr. Inglis and none to the Matron. Charlotta Ludwig, on her oath, saith. I am the Matron of St. Helens Hospital. lam a trained general nurse, as well as a registered midwife. I am also registered by the Central Midwives Board of England. I commenced training for my certificate in 1904. I went Home to England in 1902. I then had had no experience. I got my training in the Nottingham General Hospital. I was there three years —1904 to 1907. I then had a long holiday and took midwifery training in Plaistow. I came back to New Zealand in 1908. I was then four months in my own home. I was submatron in St. Helens Home, Christchurch, from October, 1908, till February, 1910, when I was promoted to my present position. My salary is £120 per annum, with my board and laundry-work. I have the whole, responsibility

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of the Hospital on my shoulders. I saw Mrs. Marsh when she came to book for her confinement. That would be about two months before it. I spoke to her about general matters and about the state of her health. All I remember she said was that she had not been feeling well. I understood her to say that she had been troubled with a weak heart for several months. I keep a register of patients. I saw Mrs. Marsh on. the evening she was admitted—at about 9 p.m. on the Ist July. Her confinement was quite normal. A slight rigor and a slight sore throat on the second day were the first things I noticed. There was a rash, too. I cannot remember the hour when they appeared. I noted the rise of temperature on the evening of the 3rd July. I informed the doctor by telephone of the rigor and the rash the day I noticed them. My instructions are definite that I must report all cases of temperature and abnormal symptoms as soon as possible. As soon as the doctor informed me that the case was one of scarlet-fever the patient was isolated. I thought myself it might possibly be a case of scarlet-fever. The patient died on the 9th July. The nurse told me two nights before the death that the pulse was getting a little quick. I did not myself go in the isolation ward. A special report in writing was kept in the isolation ward, but this was destroyed. We have had about six cases in the isolation ward. In each of these cases a report was kept on separate sheets of paper. The nurse would burn these, being cases of infection. For the first few days in the isolation ward the patient was attended by one of the pupil nurses. From the time serious symptoms showed themselves she was taken in charge by a trained nurse, who remained with her till her death. The pupil nurse was Nurse Holmes. The trained nurse was, I think, Nurse Seymour. The two nurses who attended the confinement have left the institution. I have some recollection of Mrs. Williams visit. It is incorrect that I said the patient contracted fever at Dr. Keller's. I questioned Mrs. Marsh as to the rash. She told me she had been out to Ponsonby to see a doctor. Ido not think she mentioned the name. I saw the doctor on the day of Mrs. Marsh's death with regard to sending for the relatives. I sent for them immediately I got the doctor's sanction. I sent a telegram to the husband and messages to the sisters. In mild cases of scarlet-fever one has to look well into the skin to see if there is peeling. I know of nothing that could have been done and of nothing that was done that could have saved Mrs. Marsh. We did our best. The doctor came without delay, and I reported to him as soon as possible. % To the Commissioner.] As far as I remember, the doctor visited Mrs. Marsh in the isolation ward every day. The nurses in attendance there never came out of the isolation ward into the main building. I suppose the patient was on a milk diet there. No diet-sheet is kept. The milk would be put on the step and the nurse would take it in. The nurse's food would be taken in in the same way. The dishes were kept in the ward, and boiled there. The nurse kept a temperature-card in there, and everything that was done or occurred would be put down. Ido not remember seeing the temperaturecard or the notes after isolation. The temperature-card before isolation was taken into the isolation ward with the patient. The temperature-card and notes kept by the nurse were destroyed. I expect this would be done when the other things were burnt by the gardener in the garden, having been first fumigated in the ward. We have no appliance for destroying these things. The case-book was entered up after the death —I do not remember how long after. If lam very busy I let them run on a month or two before entering them up. I got some of the information out of the delivery-book we keep. I suppose I would get the information as to the scarlet-fever out of the nurse's report-book. There is a report-book in which the nurses report hourly the condition of the patients. The report-books prior to the 22nd October, 1912, to the 10th December, 1912, have all been destroyed. I was told the present one had better be kept. I destroyed the others by tearing them up and putting them in the waste-paper basket. There were no old report-books there when I arrived, and I went on in the same way. The nurses write out the notes for me. In making up the present case in the case-book I had no access to the temperature-chart or the nurse's notes. The notes are made in the case-book at any time. I might have made the entries in the book relating to Mrs. Marsh any time—it might have been weeks after the event. I copied the entries from the notes of Nurse Holmes. Either myself or the assistant matron is present at every delivery. A special nurse was appointed to the isolation ward.' The entries in the book were written in by me from a draft prepared, by Nurse Holmes. I got the statement " that the fever was of a mild form " from Dr. Inglis. I suppose the doctor told me that the patient showed symptoms of heart-failure on the 7th, gradually got worse, and died on the 9th. The relatives were notified of the critical condition of the patient on the morning of the 9th. I did not consider it was necessary to notify the relatives earlier. I got the information that the patient had been treated for a weak heart from herself. The nurse was changed on account of the appearance of the symptoms of heart-failure. Nurse Seymour then went in in place of Nurse Holmes. Nurse Seymour is out of New Zealand now. She was called in from the Nurses Institute. Nurse Holmes was a pupil midwife. She had been six months in the home. The patient was in the isolation ward from the Monday to the Saturday. I did not look on the case as a serious one till the very end. We had no fear of her at all. There is no book in which the Medical Officer enters his report for my information. All his reports to me are verbal. If he comes'when lam busy the assistant matron attends to him, and she puts on paper anything special that the doctor says. The deliverybooks are torn up. A visitor's'book is kept Jor people who wish* to look round, but there is none kept for friends of patients. [By consent, cross-examination deferred.] Tracy Russell Inglis, recalled. To the Commissioner.] I see from my card that I attended Mrs. Marsh on the 2nd, 3rd, 4th, sth, 6th, early in morning of 7th, Bth, and"9th"July. The patient first showed symptoms of heart trouble on the Bth, as far as I remember. She rather got suddenly worse on the 9th. I talked the case over with the Matron each day. I made no record in the case-book or anywhere else.

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Tie Mrs. Porch. — Complaint No. 1. Florence Keller, sworn, saith. I do not consider a labour of 63 hours 25 minutes a normal labour. 1 have heard that MrsChamberlain died in the isolation ward on the 9th September about midnight, of puerperal septicaemia > that her body was removed on the 10th September, about 8.30 a.m.; that on the 10th September, in the evening, Mrs. Porch was placed in the same ward ; that she was there attended by the same nurse —Nurse Adams —who had attended Mrs. Chamberlain ; and that the patient was removed thence to the General Hospital suffering from pelvic abscess. I do not think, under those circumstances, it was proper to put Mrs. Porch in that ward. I would condemn that practice. I would condemn the practice, though the place was thoroughly fumigated. If they used formaline there would be enough fumes left in a few hours to set up irritation of the mucous membranes of the incoming patient. I think it was equally grave that Mrs. Porch should have been nursed by a nurse who had nursed Mrs. Chamberlain, who had died of puerperal septicaemia. In a case of puerperal septicaemia at the Army Home the nurse was isolated for a month. In this case the patient did not die. Cross-examined by Mr. Mays.] I did not know that Mrs. Porch was septic for five days before she was put in the isolation ward. If the ward had been disinfected thoroughly, and I knew the patient had been septic.for five days, I would not want her put in there if she had been a patient of mine. It would only add to the infection. The fact that the woman's septic condition improved rather than got worse would tend to show that the infection had been destroyed by the fumigation. I have had experience of the naidwives that have been trained at St. Helens, and think very highly of them. I am glad to get them when in need of their services. Re-examined.] It was not justice to the two other women who were occupying the room to allow Mrs. Porch to remain in the room with them for five days when she was known to be suffering from puerperal fever. Such patients should be isolated till it is ascertained what is the matter. Herbert Myer Goldstein, on his oath, saith. lam a duly-qualified and registered medical practitioner practising in Auckland. At various times I have acted with Dr. Inglis, and sometimes for him at St. Helens Hospital. Amongst others, I attended Mrs. Martha Porch, at St. Helens. I was sent for by the Matron as it was a case of difficult labour. To effect delivery I had to administer chloroform and use forceps. I decidedly think the Matron sent for me at the right stage. I had been at the Hospital earlier in the day and had the case explained to me, and I take all responsibility from that time onwards. After delivery, the patient did not recover normally. Her temperature was unsatisfactory from the next day. Her demeanour became strange from the evening of the second day, until she became practically insane—a case of puerperal insanity. She refused to take food, and had to be forcibly fed. On the fourth day Dr. Inglis and I saw the patient together. Dr. Inglis then took charge of the case. I know of Mrs. Chamberlain's case, and that she died at midnight on the 9th, and that Mrs. Porch was put in the same ward on the evening of the 10th. If the ward were thoroughly fumigated, I think that, under the circumstances, to put Mrs. Porch in the same ward was the only thing to do. Mrs. Porch's condition so far as her septic condition was concerned got no worse, and her recovery would seem to indicate that the means taken to disinfect the isolation ward were complete. I have seen the Matron at work in the Hospital. I consider her absolutely qualified for her position, and that she can be trusted to exercise her judgment and discretion soundly. Cross-examined.] I was told when at the Hospital at 11 a.m. of Mrs. Porch's case and of her condition at the time, and I gave instructions to send for me when the case had reached a certain stage. It would have been harmful for me to have interfered sooner. I knew of the long stage of labour she had gone through. It is very hard to say what is a normal labour. This one was an abnormal labour to a certain extent. Anything done sooner that I did it would have absolutely risked injuring the patient. It was not abnormal to that extent. I do not know that the woman was without sleep during those three days of labour. A protracted labour brings on sleeplessness. [Mrs. Nicol states that she will formulate no more complaints, except to enlarge that of Mrs. Porch.] Tracy Russell Inglis, recalled by Mr. Mays, saith. I first saw Mrs. Porch on the Ist September. I was ill when she was admitted, and Dr. Goldstein attended her on my behalf. I think I took the case over from him on the 4th September. On the Ist September, when I saw her, she was strange in her manner, showing early signs of puerperal mania, and she had a temperature. I produce the chart. [Exhibit No. 5.] I conferred with Dr. Goldstein as to her condition. We came to the conclusion that she was developing puerperal mania. Dr. Goldstein continued to attend her till the 2nd September. I took over the case on the 3rd September. I attended the patient daily after that. One day I had Dr. Goldstein with me. The patient was then in a room by herself in the main building. That day I gave her a interuterine douche. That was to make sure that nothing was left behind. She was removed to the isolation ward on the night of the 10th September. That was because the isolation ward was free. I attended her there till she was removed to the General Hospital. I attended her there, too. She recovered. I ordered the removal to the isolation ward. I knew of Mrs. Chamberlain's death there from septicaemia. I gave instructions as to what was to be done before Mrs. Porch was removed there. I instructed the nurse to have the place thoroughly disinfected and to see that the nurse disinfected herself. I consider that under the circumstances the removal to the isolation ward was the best and proper thing to do. I tried to get other accommodation. From the time I first saw her there was nothing done or left undone to which I could take exception. Patient had not fully recovered her mental condition when she left the General Hospital. The Matron telephoned me what she was doing in the case. I considered the means taken sufficient. I was frightened of the woman getting out of the window. She

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mvle several attempts. Her septic condition got no worse in the isolation ward. The removal to the isolation ward was not in the slightest detrimental. The Hospital is not suitable for its purpose. I reported to this effect in the first year. Cross-examined.- —I gave orders myself for the disinfection of the isolation ward. Ido not know who did the actual wort. I had perfect confidence in the Matron that she would do it thoroughly. I know that you have been wanting an inquiry into St. Helens for some time. That had nothing to do with the destruction of the books. Re-examined.] Up to the 22nd October last this inquiry was not mooted. The books have been destroyed periodically. I knew they were destroyed in the first three years. I made no inquiries after that, as it was the usual custom. The destruction has gone on since without any protest from any one. [Mrs. Nicol states that she does not suggest that the books were destroyed in view of an inquiry. She states, further, that she is satisfied with Dr. Inglis's answer on the subject.] Adjourned till the 21st, at 10 a.m. Tuesday, 21st January, 1913. [Mrs. Nicol hands in further complaints re Mrs. Porch. Mrs. Nicol states that she has no further complaints to lodge.] Angelina Allen, recalled for cross-examination, saith. ' Cross-examined by Mr. Mays.] I was quite satisfied with my treatment by the Matron and the staff as far as I myself was concerned on both occasions. The tear in the which the Matron stitched up on the first occasion healed up all right. On each occasion when I left the Hospital I was in a fit condition to nurse a baby. lam sure the Matron told me to take the baby—when I took it back to the horne —to the chemist. The Matron told me to take the baby to a chemist, and if I did not find the child got on all right to take it to Dr. Sweet. I then had the child with me, and showed it to the Matron. I had not taken the child to a chemist before this. A chemist had not prescribed for the first child. I did not mention chemist at all to the Matron. I thought I would rather take the child to my own doctor than to Dr. Sweet. I did not know about the child being sore on the buttocks till the Matron told me on the day I was leaving. The Matron told me then that the child had diarrhoea. She told me to get some Fuller's earth, and make it into a paste and put it on. She gave me no other directions. I got and applied the Fuller's earth. The child was very cross and very greedy, as well as having the soreness and diarrhoea. To the Commissioner.] When I was discharged there was no discussion between me and the Matron or nurses about leaving my baby there. Ido not know if I would have left it if the Matron had wished me to leave it there for treatment. It did not enter into my mind at all to leave the baby at the home for treatment. Re-examined.] I am sure that the Matron told me to take the baby to the chemist, and not to a doctor. I knew before I left the home—on the day I left —of the raw buttocks and the green motions. I understood that when I was discharged the baby and I would have to come away together. Charlotta Ludwig, recalled, as to Mrs. Porch's case and Mrs. Allen's case. [Copy of Mrs. Porch's case from case-book put in. Exhibit No. 52.] To the Commissioner.] I recollect Mrs. Porch being admitted to the Hospital. That was on the 28th August, 1912. It was a case of protracted labour. Labour began at 1.30 a.m. on the 28th August. Ido not remember if I saw Mrs. Porch on her admission. There is no record kept of such. I saw the patient quite early in labour. When the patient first comes in she is prepared by a nurse. I select the nurse for that purpose. The preparation is done in the bathroom. The patient is taken next to the nursery, where she is watched, though not necessarily by the same nurse. It is the duty of the senior nurse on each duty to do the watching. Cross-examination-in-chief continued.] I cannot recollect at what hour I first saw Mrs. Porch. I saw her in the first stage of labour. I cannot say where or what nurse was with the patient when labour began. Dr. Goldstein was not sent for till the 30th August. He was not specially sent for. He was there on other cases, and I described the case to him. He instructed me to call him when it was time —that was, at the end of the first stage. I sent for him in due course. He came. He attended to the actual delivery of the child. From the beginning, I believe, Mrs. Porch's temperature rose. It did not come down. After a day or two she became strange in her manner. She was a little peculiar on the second day, and she got more strange as time went on. I think it was on the fourth day that she became violent and practically insane. She attempted to get out of the window. She was never left alone. After that time she refused to nurse her baby and to take food herself. On the" sixth or seventh day Dr. Frost reported the presence of streptococcus. At this time Mrs. Chamberlain was occupying the isolation ward. She (Mrs. Chamberlain) died on the 9th September. Mrs. Porch was on the labour-bed for some hours. They are usually put on the labour-bed at the end of the first stage. The patient was in room No. 8. There is nothing there beyond the hot-water bottle to keep the temperature up. There is no fireplace in the room. It was, I think, in the afternoon that she was put in the labour-bed. That was at the end of the first stage of the labour. It might have been at 1.30 p.m. on the 30th. She would be kept there till the end of the third stage. She would probably be kept there three or four hours. From the record she was four hours and twenty-five minutes on the labour-bed. The so-called labour-board is a bed kept rigid under the mattress with boards, with blankets and a hot-water bottle. It is specially kept for the purpose. Dr. Goldstein was present oV ; ig the greater part of the four hours and a half. I cannot say the temperature of the room. I

37

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saw no sign of the patient having taken a chill. Miss Broadley (the sub-matron) and Miss Brawn were present during labour. A slight shivering fit very often occurs at the end of the third stage of labour, due to the reaction. A. patient during her first confinement might easily take that for a chill. Dr. Goldstein told me he could do nothing till it reached the end of the first stage. I cannot say if he mentioned that it was no use his coming till the head was well down in the pelvis. I think he came about an hour before the end of the second stage. Before the doctor arrived I administered two doses of hyoscine. The object of that is to hasten the dilatation. I usually give this at night. I cannot say that it hastened the dilatation in this case, but it induced sleep on each occasion. Patient slept for Several hoiirs after each dose. The allegation that the patient had no sleep during this protracted labour is quite incorrect. There was no reason whatever during the first forty-eight hours after her admission for calling in a doctor. Dr. Inglis was ill at this time, and his work was being performed by Dr. Goldstein. Dr. Goldstein was present in the morning, and I told him of Mrs. Porch's case. He then told me what to do as regards getting him. Dr. Inglis told me to call Dr. Goldstein when I wanted a doctor. Ido not remember Mrs. Porch having a cough at all. She could not have had a bad one, or I would know of it. If she had a severe cough, it would be recorded in the report-book. After Mrs. Chamberlain's death on the 9th September I communicated with Dr. Inglis as to disinfecting the ward where she had been, and as to what was to be done with Mrs. Porch. Dr. Inglis told nic what to do. His instructions were verbal. He said it would be sufficient if the walls, ceiling, and floor were washed with disinfectant, bedding burnt, and all clothes soaked in disinfectant before going to the laundry. By clothes are meant sheets, pillowslips, blankets, and everything which had been used by Mrs. Chamberlain, except the blankets and mattress. The nurse was to have a disinfectant bath, her hair done, and all her clothes disinfected in the usual way. These instructions were carried out to the letter. Jeyes fluid was used. The room was not fumigated. This was an urgent case, and we could not wait for the Health Department Inspectors, who come sometimes three days after they are wanted. I reported to Dr. Inglis by telephone what Bad been done. He said that would be sufficient. Mrs. Porch was then removed to this ward. From that time onwards I had nothing personally to do with the patient further than making necessary inquiries. Mrs. Porch was taken to the General Hospital on the 18th September. Mrs. Chamberlain died on the 9th September. Her body was removed about 8.30 a.m. on the 10th September, and I believe Mrs. Porch was put into the isolation ward the same evening. I recollect Mrs. Allen's two confinements ; at least, I think I can. So far as I recollect, they were both normal. I remember Mrs. Allen calling at the home about her baby. I could not swear as to what advice I gave her. I never told anybody to take a child to a chemist. To the Commissioner.] The patients usually bring up the subject of their discharge. As a rule, an indication is given them that they must move on a certain day. Mrs. Allen left on the 14th or 15th November with her child. She was quite fit to go. There was nothing to cause any anxiety about the child. It was apparently quite healthy. There was nothing at all to suggest to me that I should keep the child under Rule 13. Examination-in-chief continued.] We could not keep every child that was a little raw or had diarrhoea. If there was any doubt as to the safety of letting a child go out of the home, we would keep it. I never advise separating a mother and child when the mother is able to nurse it. I remember Mrs. Allen coming back with the child. I cannot say the date. She told me that its buttocks were raw, and it had diarrhoea. I think she said it was vomiting. lam under the impression that I told the woman to take the child to Dr. Sweet, in view of the fact that she had lost her first baby. I did not consider the child to be in a dangerous state. I have never advised any mother to take her child to a chemist for advice. My usual practice is either to advise them to go to a Plunket nurse or to a doctor at once. When discharged the condition of the child was satisfactory. It had had an attack of diarrhcea in the Hospital, but I cannot say that this had quite ceased when they left. The buttocks were red,,but not raw when they left. I generally give advice to the women leaving, especially when I know they are ignorant of the subject of babies. When Mrs. Allen left I told her not to wean the child till she had seen a doctor. I told her to feed the child regularly at the breast. She had been a sleepy patient, and did not feed the child regularly. The child took the breast very greedily, and I told her to prevent it from doing so, as it brought the food up afterwards ; drinking too quickly brought on indigestion. [Blrs. Nicol states that she makes no complaint in connection with Mrs. Allen other than those in writing.] I know of nothing in connection with Mrs. Allen's case, either done or left undone, that indicated any neglect of her case. I put in two stitches in Mrs. Allen. That is a customary thing. I might have been put in one or two. They were not deep stitches. Cross-examined by Mrs. Nicol.] I did not pass my degree in Germany. I was not trained in Germany. I was registeied under the Central Midwives Board. I believe it is the rule under that Board that midwives have to call in a doctor for any rupture of the perinaeum. I quite believed that Mrs. Allen's baby was in a proper state when it came out. Green motions is not a proper thing in a baby. Ido not think the baby had green motions when it left the home. It had them before, but it had recovered before leaving. When Mrs. Allen came back to the Hospital she had a witness with her. I did not tell her to go to any chemist for advice. I state that I have never told any person to go to a chemist for advice, though there was a witness present. I consider the baby was in a proper state to be discharged when it was discharged. When Mrs. Allen took the child back to the Hospital I did not at all think the child should have been taken back into the Hospital. I have no record of the time Mrs. Porch was admitted to the Hospital. The time might have been 3.30 a.m. I expect labour had begun before she came in. It generally does. She might have come in twelve hours later than the beginning of labour. Mrs. Porch might have been put in the nursery and left in a chair there till 5.30. That is not an improper thing. The time of admission might have been 3-30 a.m. I was probably in bed when the patient was received. She would be received by the night nurse. I cannot say without my duty-book who that would be. Ido not know the date of the notification of Mrs. Chamberlain's sepsis or Mrs. Porch's sepsis. The nurses disinfected Mrs. Chamberlain's room

H.—3lb.

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when she was removed to the isolation ward. Mrs. Porch was on the verandah. To get there she had to pass through the room from which Mrs. Chamberlain was isolated. Mrs. Chamberlain was not in No. 3 when Mrs. Porch was admitted. The room Mrs. Chamberlain had been in was carefully disinfected after Mrs. Chamberlain left it. It was allowed, while Mrs. Chamberlain was in No. 3, for patients and others to go through that room to get on to the balcony. At that time we were not aware that the case was one of sepsis. She was put in there because of her temperature. All cases of temperature are put into a single room. No person was allowed to pass through the room after we knew that Mrs. Chamberlain's was a case of septicaemia. It is not in my province to know how long she had septicaemia before we knew it. We considered Mrs. Chamberlain tubercular, and put her in that room as the best one for her —so that we could wheel her on to the balcony. If it was known that Mrs. Chamberlain was septic, it would have been a wrong thing to allow people to pass in and out of her room. There was one other patient with Mrs. Porch in the same room. There may have been two others. I cannot say when Mrs. Porch developed sepsis. We knew of it when we heard of Dr. Frost's examination of the blood. Dr. Frost did not tell me the result of her examination. As far as I remember, I suppose it would be about the 6th September when we first knew that Mrs. Porch was septic. I think Dr. Inglis sent for Dr. Frost. I did not. Ido not know what lead to the sending for Dr. Frost. If Mrs. Porch were septic on the 6th she was in No. 6 till she was taken to the isolation ward. After labour Mrs. Porch was put in No. 2. I saw the patient lying in No. 6 before that. There were three beds in No. 2. Mrs. Porch was isolated to No. 6 before the sth September, I think, but am not certain that she was sent there on the evening of the third day. Mrs. Porch was confined in No. 8. She went thence to No. 2, and thence to No. 6. We always remove the patients after the birth. It was quite proper to move Mrs. Porch. The patient was then removed to No. 6. That was because of her mental condition. It was not said that it was suspected that she was septic. From No. 6 the patient was taken to the isolation ward because she was not safe in the room she was in, and she was septic. As there was no place to put her, Mrs. Porch was allowed to remain in No. 6 after it was known that she was septic. After Mrs Chamberlain died, and the isolation ward was disinfected, Mrs. Porch was taken there. Mrs. Porch was removed to No. 6 on, I think, the evening of the third day, on account of her mental condition. If anything else could have been done, I would rather Mrs. Porch had not been in No. 6 when she was known to be septic. The only thing that could be done was to keep her there. I am satisfied we did the best we could in the treatment of Mrs. Porch. Mrs. Porch was not at all at the very lowest point of vitality when the baby was born. I did not consider it necessary to bring the doctor in to see Mrs. Porch during all those hours of labour. I considered it an unusually long labour. Ido not consider it necessary for every woman to be seen by a doctor. lam not always sure how the confinements will end. Two stitches (not nine) were put in Mrs. Porch by the doctor. I keep the windows open while the patients are being confined. None of the patients have developed pneumonia from draughts in my time. I have always had a mattress on the labour-bed where the women are confined. I consider the labour-bed in the Hospital a proper place to put patients during labour. I have not had the charts burnt which were in the wards with puerperal-fever patients. Milk diet is given to patients in puerperal fever. Ido not order stimulants at all. I look on milk as a nourishing food. There are no written instructions given by the doctor as to diet. I have to trust to memory as to what the doctor's instructions are. The only disinfectant used in the isolation ward was Jeyes fluid. I say that that was, in my opinion, the best way to disinfect the room. As far as I know, nothing better could be got. To the Commissioner.] The gardener, Cliffe, actually did the disinfecting. Ido not think any one was present with him when he did it. He had a pail, a scrubbing-brush, and a cloth, as far as I can remember. No one supervised his work. He has done similar work before, and he is a very conscientious man. I told him what to do and where tq, get the things. I trusted to him to do the work properly. I told the man to wash down the walls and the floor. I think he did the ceiling with a broom with a cloth on it. Norman Albert Porch, on his oath, saith. My wife is at home. She is too ill to attend here. It would excite her too much to attend Court. Her trouble was mental, and the excitement might upset her again. I went with my wife to St. Helens on Wednesday, the 28th August. We got there about 3 a.m. She was doubled up with the labourpains before she left our house. I went to see her the next day, and then found her still suffering severely. She had never shown trace of insanity, and there was none in her family. I went to see my wife on Friday evening about an hour after the baby was born. I visited her every evening in No. 2 for about five evenings. Then she was removed to No. 6. I visited her there. When she was in No. 2 I thought there was something strange about her. She thought I had been killed, but that state passed off in about half an hour. I mentioned the strangeness to one of the nurses. I got no reply. In No. 6 she was insane altogether. She was removed to the isolation ward about the 11th September. She was there fully a week. Nurse Adams nursed her in the isolation ward at first, and after her Nurse Brawn. The Matron mentioned to me that Dr. Inglis had examined my wife and advised me to send her to the General Hospital for an operation for her mental relief. She went in there on the 18th, and was operated on on the 19th. She went through two operations there. Just before the second I questioned one of the doctors as to the reason for it. My wife was a perfectly healthy woman before she went in to St. Helens. I never knew her to have a day's sickness. Cross-examined by Mr. Mays.] The Matron questioned me as to my wife's family history on the matter of insanity. I did hear the Matron say something as to my mother or my wife's mother having said something to my wife which very much frightened her. Ido not think the Matron asked me to keep away the person who had frightened my wife. I was not aware that my wife refused to feed her baby. Further than that I had difficulty in getting the right baby-clothes back, and the length of time she was allowed to be in the labour-pains, I have no complaint against the Hospital authorities. For the last couple of days the child has not been thriving, though up to that it did well. Re-examined.] The child had a cold when it left the Hospital. It still has it. [Adjourned to the 22nd, at 9.30 a.m.]

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S. NEWCOMB.j

39

Wednesday, 22nd January, 1913. Mrs. Chamberlain's Case continued. Sabina New comb (called by Mr. Skelton), on oath, saith I am wife of Stanley Newcomb, of Fairview Road, Mount Eden, wholesale stationer. I knew the late Mrs. Chamberlain. She was in my employ as a domestic servant for the two years immediately preceding her marriage. She was a fine strong girl. I never saw her to be anything different. She was of splendid physique. She had influenza once, but we all had it on that occasion. In consequence of something 1 heard after her marriage I went to St. Helens Home to see her. I found that she was in the isolation ward. It was a Saturday afternoon. It was either the Saturday immediately before the Monday on which she died or the Saturday before that. I saw a nurse. I believe it was the Matron, Miss Ludwig. I do not remember much that was said. I asked to see the patient. The Matron told me that if I went to the isolation ward I could ask the nurse there if I could do so. I asked what was the matter, and the Matron told me they would rather not say, but she believed Dr. Inglis had told Mr. Chamberlain all about it. As far as I remember, that is all that took place between us. I went to the isolation ward. I saw the nurse in charge. I asked her if I might see Mrs. Chamberlain. She said I had better not see her—that she was too ill to be seen. I said that I had heard that she was not a matured girl. I said that 1 heard there was something of a chest trouble. The nurse said, " Oh, no; not at all." She seemed to laugh at the idea of that. I said that I heard she was dangerously ill. The nurse said, " Oh, not dangerously ill — seriously ill." She added that if I came next week I might see her. 1 do not think there was anything else. I was not able to see Mrs. Chamberlain. Gross-examined.] I saw nothing of Mrs. Chamberlain after she left my place and before she entered the home. Robert Briffai lt (called by Mr. Skelton), on his oath, saith. I am a duly-qualified and registered medical practitioner, practising in Auckland. ] am an. M.8., Ch.B., University of New Zealand. I was surgical assistant at Chelsea Hospital for Women and surgical assistant at Soho Hospital for Women. I specialized in gynaecology. I have read the depositions taken in this case of Thomas Chamberlain, Sadie Finer, Louisa Hunt, and Walter Scott Brockway. and am accordingly aware of the facts to which they refer. [Mr. Mays puts in the original temperature-charts in Mrs. Chamberlain's case, kept at St. Helens Hospital.] Looking at the charts, considering that she had a temperature of over 101 on the first day and 101 on the second day, I think I can say that on the second day the case should have been reported to the Medical Superintendent. 1 say this apart from the rules and regulations altogether. The fact of the temperature lasting into the second day indicated that it wanted attention. I say most decidedly that the case was one requiring medical attention immediately following and including the second day. I consider that a suture should never be inserted by a duly-qualified midwife without the medical man's authority. Personally, I should not authorize it. If the case were reported by the midwife, and the medical man was satisfied that the case was not serious, he might in exceptional cases authorize her to insert the suture though he had not seen the case. In my opinion, a midwife is never justified in inserting a suture. In my opinion, it would be wrong for a medical man to authorize a midwife to do it except in his presence and under his direction. In cases of absolute necessity I would, of course, approve of the midwife suturing where the services of a medical man could not be obtained. The midwife would under no circumstances be entitled to use instruments. Assuming that the midwife had the knowledge how to use the instruments, and the services of a medical man were unavailable, then the midwife might use them, though it is likely that more injury would be done than without them. In a city 1 hold it is quite inexcusable for a midwife to insert sutures. The profession as a whole is opposed to it. In my opinion, and I voice that of the profession generally, no person other than a medical practitioner should be allowed to insert sutures or use instruments, this being qualified as to cases of absolute necessity. No midwife is actually trained to surgical operative measures. It is outside the sphere of her training altogether. She cannot therefore be expected to be experienced in properly cleaning up a wound and bringing the tissues together in a proper way and avoiding the dangers of such a thing as septicaemia. [Mr. Skelton refers to Rules 17 and 35.] I am aware that it is quite a common practice for the Matron in such homes as St. Helens, both here and at Home, to insert sutures in ruptured perinamms. I condemn the practice entirely. It would not be tolerated in private practice, and a home like this should be better, not woise, than private practice. I see the note in the case-book: " Perinaeum ruptured, second degree." If the rupture were a minor one, following the practice in these homes it might pass without the necessity of calling in the medical man. In common medical language it would not be called an abnormal labour because there was a rupture of the second degree. Apart from the rules and. regulations, it is not a normal case where there is a ruptured perinaeum of the second degree, distended abdomen and offensive smell on the fifth day. [Mr. Mays says that he does not ascribe the cause of Mrs. Chamberlain's death to direct contact with her mother's ulcer.] If the patient complained on- the day following the confinement of throbbing pain where the sutures were this would indicate inflammation at the site of the sutures —that is, if the pain were properly described as throbbing. It is a very common thing for a woman to complain of pain at the site of the suture, but the pain couid hardly be described as throbbing if the sutures were clean. If the patient said the throbbing still continued, and others noticed a very offensive smell and a distended stomach, and assuming these things to be correct, they would point to a certain amount of septic trouble. That is borne out by the character of the chart as a whole—temperature and pulse. Speaking from the chart, I say

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that the presence of septicaemia should have been suspected at the very least on the third day. There are notes as to the giving of injections of streptococcus vaccine on the sth September. An exudation of black blood and matter from the patient's breast on fifth day might have been an indication either of local inflammation of the breast or of general septicaemia. Cross-examined by Mr. Mays.] 1 have had considerable experience of nurses, both general and widwives. There are decidedly some on which I would place, more responsibility than on others. In. the case of a nurse that 1 knew very well, and in whom I had implicit confidence, I might feel that I was taking no risk in allowing her to ptit a few stitches in simple wounds, but I would, as a matter of principle, endeavour to avoid' doing it. A midwife who is also a trained hospital nurse, and who has been for three years in charge of a maternity home ought, to be a person in whom I could place such confidence, and who could be entrusted with putting a few stitches in a small wound. I do not see that the fact that there is a medical man attached to the home who can be called any minute makes any difference, though i am perhaps justified in saying that it makes the risk less to the patient. A. ruptured perinaeum is sometimes painful though no stitches are put in, and sometimes not. It is one of the most sensitive parts of the body. Sutures can be put in without causing any pain at all—that is, after-pain. Sutures of the perinaeum are usually felt; occasionally they are not. Stitches could not be put in the perinaeum without being felt at the time, and it is possible that they might not be felt afterwards. I have known of such a case. If Mrs. Chamberlain's wound had been septic at the time of sewing up it could not have healed by first intention. If the sepsis had been introduced by the sutures or by contact with the Matron's fingers or by the neglect of common precautions inflammation would set. in within, say, twenty-four hours. The condition would become very much worse each succeeding day—that is, the condition of the patient, not necessarily the condition of the perinaeum. To the trained eye the fact that sepsis had been introduced would be visible there and then from an inspection of the perinaeum. I cannot imagine such a case as the following. The case of a woman with a ruptured perinaeum which had been sutured and sepsis introduced during the process of suturing and the perinaeum not only not showing any signs whatever of septic poisoning but outwardly healing as if by first intention. The lochia discharge without, sepsis has a smell which a layman might describe as unpleasant. The term is used in text-books as being of a " sickening odour." I would not say that the chart could not be one of chest trouble or tuberculosis. A tubercular condition is one of the first conditions that childbirth lights up. I could not put it that childbirth predisposes to consumption. I put it that childbirth may offer occasion for the outbreak of latent consumption. Assuming a patient to be run down before and more after childbirth, due to overwork and a phthisical condition, that would show in her temperature. Eliminating the distended abdomen, the throbbing perinaeum, and the offensive smell and the discharge from the breast, 1 say that a patient suffering from overwork and a phthisical condition would be some time before she would be fit for discharge. If the patient lay in that condition without improvement for a fortnight she would be an easy prey for any sepsis she might have about her. Streptococcus bacilli are universally present. A person in robust health can resist their inroads. The lower the person's condition the more liable to attack. The practice in England where a patient is suffering from* septicemia, or is suspected of it, is to treat with antiseptic douches. Vaccines are extensively used; large doses of quinine are sometimes given; saline injections (subcutaneous) are often used. Those are the chief methods. Beyond that, nothing much can be done. The diet is a low milk-diet. The first move must be the building-up of the vitality of the patient. In every bacterial condition the resistance of the patient is an important factor. Nurses should be trained in antiseptic methods. The regulation on the subject refers to quite a different matter from a practical knowledge of how to treat wounds. I have had occasion to call in in my private practice nurses who have been trained in St. Helens. My experience is that they have been thoroughly satisfactory. If the Matron were septic when she put in the sutures I would expect complications to arise in connection, with a caesarian section at which she was present and assisted a few days later. I would expect trouble at the caesarian section if the Hospital were seething with sepsis at that time. 1 have had no experience of training midwives. I can offer no opinion as to how the New Zealand ones are trained in comparison with those trained elsewhere. Gross-examined by Mrs. Nicol.] The risk was not necessarily greater in a maternity hospital in putting in the sutures than in a private-practice case. From the point of view of other patients, there is, of course, more risk to the others. Apart from that, there ought to be less risk. The septic germs can equally find an opening through a small suture as through a large one. The use of antiseptics has done away very greatly with puerperal fever. If trouble and expense were no obj.ect the risk of puerperal fever in hospitals could be eliminated. I quite agree that in such an institution as St. Helens women should be treated as the Queen would be. It is not satisfactory that a septic patient should be in a room which is used as a thoroughfare. I think it would have been advisable to disinfect the whole floor on which was the room in which the septic patient lay. I know of cases where s tear has not been sewn up. It is not a satisfactory proceeding. Sutures do and can become septic. I believe the British Midwives Council forbid any of their nurses to put in sutures. Cross-examination by Mr. Mays continued.] By a second-degree rupture I mean a rupture involving the muscular tissues of the perinaeum. The classification of ruptures is not very rigid. There are outbreaks of sepsis in the best maternity hospitals in the world. I know that the wives of men not earning more than £4 per week are those from which the patients are drawn into St. Helens, and I say that there is more liability therefore for the introduction of sepsis. With patients of the poorer classes there is a greater risk of sepsis, and therefore greater precautions ought to be taken. In an institution like St. Helens I should say that a mortality rate of less than \ per cent, is very creditable. That is the more so in view of the fact that many of the cases

41

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H.—3lb.

are cases of complicated labour. 1 can only suggest that the floor 1 have referred to should be disinfected one room at a time, if it is the fact that the rooms on that floor were all occupied. Cross-examination by Mrs. Nicol continued.] Jeyes fluid is a very good antiseptic. I have great faith in it. Ido not know the gardener who did the disinfecting. The disinfecting of the isolation ward by scrubbing the walls, floors, and ceilings with a strong solution of Jeyes fluid would be very satisfactory, though 1 should like, myself, to have it. fumigated with formaline. The disinfection by a gardener without any supervision does not sound right. In a properly constituted maternity home all traces of dirt on patients brought there from the slums should be cleaned away. Re-examined by Mr. Skelton.] I do not consider I am in a position to state as to what spot on Mrs. Chamberlain's body septicaemia was contracted. If the pain is correctly described as throbbing there would be a presumption that that was a seat of infection. One of the first signs of infection is inflammation. The risk of sepsis in general depends on the state of the home as to its cleanliness. To the Commissioner.] I cannot say that I know St. Helens. I know its history. It was Dr. Purchas's old residence, as a private home, at a guess, twenty-five or thirty years ago. I know the locality and the area of ground round it. Most emphatically, the site is not a suitable one for an institution of the sort. The building is not at all suitable for an institution of that sort. [Mrs. Martha Porch's statement produced by Mrs. Nicol, who states that it was made by Mrs. Porch at her house last evening; that the statement was made by Mrs. Porch without any aid in the nature of dictation or written draft, or in any other way; that her husband was present and assisted her as regards spelling some of the words; that the witnesses name —Mrs. Emily Porch—was written by a woman who was present of that name, and who is the mother-in-law of Mrs. Martha Porch. Mrs. Nicol says she saw Mrs. Emily Porch sign her name as a witness, "Mrs. Emily Porch." Mrs. Nicol says that Mrs. Martha Porch could not attend Court. Mr. Mays says he consents to the statement going in for what it is worth, subject to his right to comment on it.] Tracy Russell Inglis, recalled by Mr. Mays, saith. I saw Mrs. Allen during the time she was in the Hospital. Hers was quite a normal case. 1 believe I saw her infant. I refer to the second case. The infant needed medical attention while in the home. I saw it and treated it. So far as I saw, there was nothing that made it necessary that that child should have been retained in the home after the fifteenth day. We have retained the children where the mother has been sent to the Hospital and where the child has been very ill. As to Mrs. Allen herself, there was nothing out of the way in her confinement or afterwards. [No cross-examination by Mrs. Nicol.] To the Commissioner.] I could not swear that I saw the child on the day of the discharge, but I think I did. I inquired if it had diarrhoea. I had attended it for a mild attack of diarrhoea. It was quite fit to go out when it went. I would not absolutely swear that it had absolutely recovered from the diarrhoea. Martha Broadley (called by Mr. Mays), on her oath, saith. lam submatron at St. Helens Hospital, at Auckland. I am a general trained nurse and a registered midwife. T hold a Christchurch general hospital certificate. I also hold a certificate under the Midwives Act, obtained in Christchurch too. I was the senior nurse present at Mrs. Porch's confinement. She was admitted on the morning of the 28th August. I saw her during daylight that day—about 6 a.m. I saw her then all clay. We never leave a patient when she is in labour. Mrs. Porch was not in strong labour when she came in. The pains were few and far between. I saw Mrs. Porch right through from that time till she was delivered. She had the usual bath and the usual treatment after admission. She was given nourishment at intervals. She walked about and lay down, as patients generally do. Up to the time she was put in the labour-bed she made no complaints. She said several times, " Oh, how kind you are," and how very grateful she was to all the nurses for their kindness to her. Her eyes were shifty and unsteady. She was given hyoscine twice. On each occasion after that she slept well, on and off. It is quite untrue that she had no sleep during the whole sixty-five hours. I was present at the confinement when Dr. Goldstein was there. Dr. Goldstein was notified first thing in the morning of the 30th August that labour was progressing. T cannot tell at what stage of labour he arrived. I know it was in the morning before dinner time. He was there during the second stage, and delivered the child. The labour-bed was made up in the usual way with the usual coverings. The complaint is the very first thing T ever heard about Mrs. Porch getting a severe chill. Nine cases out of ten have a shivering fit following delivery. Mrs. Porch had this. Patient was removed after delivery to room No. 2, in which was another patient—Mrs. Williams. Later we had to remove Mrs. Porch to No. 6. She had become decidedly mental, and the patient in the room had noticed it. This patient had been a mental-hospital nurse. T recollect Mrs. Porch refusing to take food and refusing to feed her baby. She had had visitors, and some one of them had alarmed her about abscesses in the breast. After that Mrs. Porch would not look at her baby or have anything to do with it. The Matron said that these persons were not to see the patient any more. Patient remained in No. 6 till she was removed to the isolation ward. With the exception of her husband, visitors were kept away from her. - I was present at the caesarian operation that was performed in September. The results were splendid. There was no outbreaks of septicaemia. I was in charge of Rawene Hospital for some time. I say that everything that could be done was done for Mrs. Porch. Cross-examined by Mrs. Nicol.] Abscesses of the breast have not been a frequent occurrence at St. Helens. During labour the window is always shut.

6—H. 31b.

H.—3lb.

42

[m. beoadley

Re-examined.] When I was at Rawene I had to stitch up wounds. There was no doctor within twenty-four hours. No evil results followed the stitches put in by me. I was four months without a doctor. To the Commissioner.] I know the report-book. Anything that occurs, anything that is given, and all orders from the doctors are put down in the book as it happens. The report-book would contain entries about Mrs. Porch's condition and her treatment. If it is only an extra drink it is put down in the book. Each nurse initials the entry made by her. If I got instructions from the Matron I put them down. If I get instructions from the doctor I would pass them on to the Matron, and she would either put them down or tell me to do so. My salary is £80 per annum. Isabella Thompson (called by Mrs. Nicol), on her oath, saith. lam the wife of Isaac Thompson, Government messenger. I remember Mrs. Angelina Allen going into St. Helens Hospital. I knew her, and have known her for some eight or nine months. I saw her the day after she came out of the home. I saw her at my daughter's house. I am sure this was the day after she left St. Helens. I saw the baby. The mother took the cloth off the baby. The baby was in a shocking condition. It was almost raw, like a piece of steak. The rawness extended from its waist right round the buttocks. There had been a motion in the cloth that was taken off the baby. This motion was green in colour. It was diarrhceal. I do not know about the baby being in a fit state to come out of the Hospital. I think the baby wanted treatment by an experienced person. It wanted some one to look after it that had experience. The baby did not seem to improve when I saw it three days later. It was very ravenous. To my mind, this indicated that the mother's milk was not nourishing it. I knew that the child was being brought up on the breast. I told the mother to take the baby to a doctor as it was being starved, and that she had no milk to satisfy it. I saw it again the day before the mother took it to the Hospital. It did not seem any better. Its eyes looked peculiar and it had wasted away. [No cross-examination by Mr. Mays.] Mrs. Nicol asks for an adjournment, on the ground that she is physically unable to carry on. Adjourned to 23rd, at 10 a.m. Thursday, 23rd January, 1913. Re Mrs. Chamberlain's Case. Tracy Russell Inglis, recalled by Mr. Mays, saith. To the Commissioner.] I cannot produce any correspondence relating to my appointment. I do not know what became of it. I was appointed in June, 1906. I cannot give the exact date. I think it was the 14th June. I do not know if it was gazetted. I have with me and produce my ledger-cards and day-book. My day-book shows every attendance I have made at the Hospital. The cards are made up from my day-book. Some years I entered the fact of my visits to the Hospital in a diary in the Hospital. This diary was last kept the year before last. It would cover the period of Mrs. Marsh's case, perhaps. This year there was a diary provided, and it has been regularly entered. No prescription-book is kept. I usually wrote my prescriptions on pieces of paper. We keep a lot of stock mixtures. The prescriptions were kept by the chemist, and there is no prescription-book in the home showing what has been prescribed. To Mr. Mays.] I first saw Mrs. Chamberlain on the 12th August. That was the first day after the birth of the child. I am quite clear on this. I spoke to her. She had a temperature, to which the Matron called my attention. It is the duty of the Matron to draw my attention to any abnormalit}- in the puerperium—high temperature is an abnormality. I examined Mrs. Chamberlain to see how she was. She said she was quite well, except for a cough. 1 asked her if she was nervous. She seemed a little nervous. She told me she had a cough for some little time, and I remarked that she seemed run down. I then told the Matron that I would prescribe for her in a day or two, after the milk had established itself. Each day's work —the number of visits that I intend to make —are set down on the right-hand side of the little book I keep. As I make the visits I cross them out. My ledger-keeper then, at the end of the month, when he is making up the cards, also crosses them out. I have heard the statement by Mr. Chamberlain that his wife told him that I did not visit her till the third day after her confinement. That is absolutely incorrect. I visited her on the third day after her admission, and it is correct in that sense. Ihere was nothing that I know of in her condition on the 11th that necessitated me seeing her. I saw nothing on the 12th to lead me to suspect that it would be a case of sepsis. Temperature is often up on the second day—a reaction temperature. I next saw the patient on the 13th. She then said she felt very well, but she still complained of a cough. I asked her if she had any pains. She said No. I examined her chest on that day, and found crepitations of various parts thereof. I thought it indicated a state of bronchial pneumonia. It indicates really patches of inflammation scattered over the lungs. I did not examine the perinaeum. I next saw the patient on the 16th. She was still running a temperature, and still had a cough. I examined her abdomen. The uterus was involuting well. [Mr. Skelton asks that witnesses be ordered out of Court. Witnesses are accordingly ordered out, and warned by the Commissioner.] I could not find any tenderness about the abdomen. I examined the perinaeum. The discharge was normal. It was healing, and there were at that time two stitches in it. There was nothing at all to then indicate a septic con-

43

H.—3lb.

T. R. INGLIS.

dition of the perinaeum. It is not possible for sepsis to have been introduced when the stitches were put in and to be in the condition I saw it on the 16th instant. It was healing well. Had the sepsis been introduced at the time of the suturing I think it would have been inflamed, and there would probably have been pus coming from it when I saw it on the 16th. Up to this time Mrs. Chamberlain had not complained to me as to any pain arising from the stitches or of any pain in the region of the perinceum. The discharge was quite normal. I saw the patient next on the 17th. The condition was about the same. I still thought the temperature was due to chest trouble. She still had the cough. She complained of some pain when she coughed. This was just before the csesarian-section operation. I would not have done the cEesarian section had there been septicaemia in the Hospital. I saw her next on the 19th. Temperature on 17th was 103. I did not check the temperatures. I made no examination at this visit. I never take a temperature myself, though I sometimes get a nurse to take it while I am there. On the 19th I thought the patient was just about the same. She made no complaints except as to the cough, which she had somewhere about this time. Ido not think I saw her on the 20th. That was the day I performed the csesarian-section operation. This is one of the biggest obstetric operations. The Matron, Miss Broadley, and Dr. Goldstein were present. Dr. Stride was there, and gave the anfesthetic. I think there were pupil nurses there too. The operating-room was crowded, though I was not hampered in my movements. If there were sepsis about the building or in the persons present at the operation I think the patient would have been infected. At the time I decided to perform the operation I was quite satisfied that there was no sepsis in the building. I was "confident that none of the patients were septic. The patient healed by first intention. I next saw Mrs. Chamberlain on the 21st. Her condition was then much the same. Just about that time I examined her very carefully. The uterus had involuted perfectly. This was somewhere between the 20th and 24th or 25th. On the 21st my opinion was gradually being formed that the trouble was entirely a chest one. I have had similar cases before. I saw the patient every day from that on till I was ill. On the 28th August 1 was laid up. I think it was about the 24th that I ordered her removal to the isolation ward. The continuing temperature on the 23rd caused me to think she ought to be isolated. The patient asked me several times if she could not get up. She said she felt well. I told her she could not get up till her temperature came down. On the 24th, when I ordered her removal to the isolation ward, I did not think the case was one of sepsis. Had the case been one of septicsemia I think the patient would have felt a general feeling of ill health. She would quite possibly have felt pain in the abdomen. I examined her carefully on the day she was removed to the isolation ward. I saw her there on the 25th, 26th, and 27th. She was then still running a temperature, and was not as strong as she had been before. On the 27th I saw Mrs. Chamberlain, and from the fact that patients who have had a continued temperature in the puerperium there is a possibility of them developing sepsis, I thought it wise to notify the Health Department. I produce the notice I sent. [Exhibit No. 58.] It is dated the 28th August, 1912, and is from Dr. Inglis to District Health Officer. 1 notified it as a suspected case. It is very difficult to say when the septicaemia actually occurs. I was ill on the 28th August. I got up first on the Ist September. Against the wish of my medical adviser I went to the Hospital that day, and paid a visit to Mrs. Chamberlain. That is the only visit I paid that day. From the 28th August my place was taken by Dr. Goldstein. I paid no visits on the 2nd .September. I saw Mrs. Chamberlain on the 3rd. Her condition on the Ist did not satisfy me. I did not think she was improving. I thought she was developing some form of infection. When I got home I asked Dr. Goldstein to arrange a consultation. He saw Mrs. Chamberlain with Dr. Lindsay on the Ist September. I saw her on the 3rd September. I then thought her condition was more suggestive of infection supervening on the chest trouble. I arranged with Dr. Frost to take a blood-test. This blood-test was sterile. Then Dr. Frost, at my request, took a swab from the uterus. On the 4th, or early on the sth, I got the report from Dr. Frost to the effect that streptococcus had been found in the swab. It was a verbal report. On the sth a vaccine injection of 10,000,000 was made. I thought the patient was a little better on the 6th, but not sufficiently better to satisfy me that the vaccine had done very much good. I increased the dose to 25,000,000 on the 7th. There was hardly any improvement at all. I think it was about the 4th that the patient showed definite symptoms of a general infection. On the 9th she had an injection of 50,000,000. The patient died on the night of the 9th. I saw her just before she died. I visited her every day from the 3rd September to the day of her death, on which day I saw her twice. In addition to the vaccine injections, the patient had saline injections. These are given with the idea of diluting the poison in the blood. She had digitalis, with the idea of keeping the heart stimulated. We tried to give her as much nourishment of a kind easily assimilated as possible. She had stimulants, I fancy in the form of brandy. I prescribed all her treatment. I directed that a •trained nurse be placed in attendance on her after her isolation. I thought the case was one requiring a trained rather than a maternity nurse. I thought she was suffering from bronchial pneumonia. To the Commissioner.] I think I wrote out prescriptions for Mrs. Chamberlain during her illness. I gave nothing beyond verbal instructions. I never give anything else. I did not examine the nurses' report-books from day to day. I had absolute confidence in the Matron. The report-books are for the nurses and the Matron, and not for the medical man. Ihere was no consultation before performing the csesarian seotion on Mrs. Mellish. That is a major operation. There is a definite rule at the General Hospital that all operations are preceded by a formal consultation. The resident there enters the case for consultation. The surgeon who has charge of the bed will be the operator. Very often he does not consult with any one. Two other members of the honorary medical staff see the case, and if they agree that an operation should be performed they sign the book, and the operation is performed by the medical man in charge of the bed. If the two disagree there is then an actual consultation

H.—3lb.

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[t. b. inglis.

with the practitioner in charge of the case. At St. Helens 1 can perform an operation without consulting with any one, though I have the right to call in an outside practitioner. The isolation ward had not been used for some time—some weeks, probably longer —before Mrs. Chamberlain was put in. It is always cleaned after a case. I leave that matter for the Matron. I assumed that it was thoroughly disinfected after the previous case. I know it was, because I asked the Matron. 1 cannot say why it is that the notice to the Health Department was dated the 28th August and that it was only received by them apparently on the 9th September. To Mr. Mays.] To the best of my recollection 1 first saw Mr. Chamberlain on the night of the day on which she was removed to the isolation ward. He called on me at my surgery. He asked me concerning his wife. I told him i was glad to have an opportunity of discussing her case with him. I inquired as to her chest history, and I told him that in my opinion she had chest trouble. He asked me if it was consumption. I told him I thought it was an early form of that disease. I think on this occasion we had some talk on the general prospects of his wife's recovery. 1 told him it was difficult to say what the ultimate result would be. On leaving I asked him if he was satisfied with the treatment. He said he was perfectly satisfied. He did not then, repeat to me the complaints he said his wife had made to him. Had he done so I would have made inquiries at once. He called on me the next night. He asked me if Dr. Brockway had rung up. I told him he had. He said nothing about calling in Dr. Brockway. He went away saying he was perfectly satisfied. When Dr. Brockway rang me up he asked me about Mrs. Chamberlain's case. I explained the case to him as fully as I. could—the whole case up to date. He asked me what were the rules of the home as to the calling in of external medical assistance. I told him that under the rules I was empowered to get extra medical assistance when 1 required it. He said, "Does that refer to consultations," or words to that effect. I think the conversation ended there, with the exception that I told him that if he wanted to know anything further about the case I would be only too glad to let him know. I told him fully about the case, because I thought he was really asking on account of the husband. Dr. Brockway did not ask me if he could see the patient. I did not give him to understand that a patient could not nominate a practitioner to consult with me. I gave him to understand that the patient could not be attended by their own attendant. I would quite possibly have agreed to Mr. Chamberlain bringing in his own medical man to see the patient as a friend. I think it would be permitted for a patient to bring in another medical man to see her as a friend, but not as a practitioner. That has been done time after time. 1 would not have consented to Dr. Brockway visiting this patient, and to my conferring with him as to her condition. The first reason is that he is a junior practitioner to myself; secondly, he does not make a specialty of that part of the work; and from the foregoing, 1 did not think his opinion would help me at all. Chamberlain came to see me again at my surgery. He mentioned the subject of consultation. He asked me if I. thought one was necessary. I explained to him the reason which we require for consultations. 1 told him they were required when the medical man in charge wished for further advice, and also where the relatives of the patient wished further advice. He then asked me if I wished a consultation. 1 said, " No," 1 was absolutely satisfied about his wife's condition —that is, as to what she was suffering from. I did not at that time think she would die within a few weeks. 1 thought she would recover sufficiently to leave the home. I thought she was suffering from early tuberculosis. 1 thoroughly explained to Chamberlain wdiat the condition was. Chamberlain asked me whether I would like Dr. Brockway to see her with me in consultation. I think he put it that way. I replied that if we had a consultation 1 would prefer either a specialist or a senior member of the profession. Nothing whatever was said about the British Medical Association. 1 am sure of this. I deny saying anything about the British Medical Association. I have never refused to consult with a man on the score that he was not a member of the British Medical Association. I mentioned the names of some men whom I would be willing to meet in consultation. 1 mentioned Drs. Lindsay, Bull, and Robertson. Chamberlain then asked me did I really think a. consultation was necessary. 1 told him that directly I thought a consultation necessary I would get a consultant. Chamberlain did not say that Dr. Brockway was his family doctor. He said he was quite satisfied to leave the case in my hands. I toid Chamberlain my qualifications, and some of the results of my work. I heard Chamberlain's evidence. As to the material parts thereof I distinctly deny it. [Further evidence deferred, pending taking the depositions of Mrs. Bryant.] Hilda Bryant (called by Mrs. Nicol), on her oath, saith. I am the wife of Alfred Bryant, timber-worker. I have known Mrs. Allen for about twelve months. I went to St. Helens to bring her home with her last baby. As soon as we got home I examined the baby. It was absolutely raw. The Matron gave Mrs. Allen instructions as to what to do with the baby when she was leaving St. Helens. She told her to mix up Fuller's earth to a paste and apply it to the baby every time she changed it. She told her also to bring the baby back and let her see it in two or three days. This was on a Thursday. Mrs. Allen went to St. Helens again on the following Monday. I went with her. I saw the Matron. She answered the door. She took the baby upstairs while she left us sitting in the hall. When the Matron brought the baby down she said she recommended Mrs. Allen to take the baby to the chemist, and then if it got on no better to take it to a doctor. She recommended Dr. Sweet as a good doctor. When Mrs. Allen left the Hospital the Matron said nothing as to going to a doctor about the weaning of the baby. 1 lent Mrs. Allen some money, and we went with the baby to Eccles, chemist. Gross-examined.] We went to Eccles's shop at corner of Wellington Street. He gave Mrs. Allen something in a bottle—to be taken. lam sure it was the Matron I saw on both occasions.

T. B. INGLIS.j

45

H.—3lb.

Tracy Russell Inglis— continued. To Mr. Mays.] There was nothing antagonistic between Chamberlain and me. It is absolutely incorrect that 1 said to him, " You are making a great fuss about your wife. You seem to think she is of some special consequence." I do not think it is a thing I would be likely to say to any one. Dr. Brockway was the only man who rang me up about Mrs. Chamberlain. I said nothing about his getting medical men to ring me up all round the town. It is incorrect that 1 said doctors were not required, and when they were I would call in my own. The British Medical Association was not mentioned in any shape or form. Chamberlain called upon me about the time of the first blood-test. I told him that the culture prepared from the blood had proved sterile —telling him what sterile meant. He asked me whether his wife had bloodpoisoning. 1 tried to explain to him that the term blood-poisoning was very wide, and that it was quite possible that his wife was developing a general infection. I told him I was getting a further test made. He next called at my surgery after Mrs. Chamberlain's death for a certificate. I was in bed unwell at the time. I gave the certificate required. In the certificate 1 gave the cause of death as puerperal septicaemia and heart-failure. I heard Chamberlain's statement that his wife told him she had caught cold on the labour-bed. I saw nothing about her to indicate that she had caught cold there. Shivering fits nearly always follow confinement —at the end of the first and again at the end of the third stage. Mrs. Chamberlain never complained to me about the state of her breast—about blood and pus coming from it. The injection of ergotine or the like is quite usual at the end of the third stage of labour. It is usually injected into the buttock—not into the arm. There were no injections into Mrs. Chamberlain's arm under my instructions before she was placed in the isolation ward. I know of no cases of patients catching cold on the labour-bed. The labour-bed is of proper type. It is such a bed as is usually used in hospitals of the kind. If we noticed the room was cold we would take steps to heat it, or the patient. There is a proper hair mattress on the labour-bed. Two stitches were inserted in the perinaeum. If Mrs. Chamberlain stated that there were four or five she was wrong. It is usual in this Hospital for the Matron to stitch up small ruptures of the perinaeum. I regard it as a proper practice, and I think it is one carried out in other similar institutions. The rupture in this case was a small one. I do not agree that it was of the second degree. It was of the first degree. Suturing of the ruptures of the second degree by the Matron should not be allowed. That involves the muscular tissues. These were not involved in the present case. From what I see and from what I know, I believe the Matron and the nurses are very careful to see that all instruments are sterilized. The instruments are sterilized after use and again before being used again. I have always found the Matron careful, and I have heard her several times draw the attention of the nurses to the necessity for surgical cleanliness. While I have had to correct nurses in training I have never had to make any complaint as to a want of cleanliness. 1 have never had a septic case there in which I had reason to suspect that the septic condition was due to want of cleanliness on the part of the staff. I last saw the perinaeum on the day before or the day on which the patient was removed to the isolation ward. The stitches had been removed and the wound had healed as if by first intention. Mrs. Chamberlain's septic condition cannot, in view of this, be attributed to the sutures. Mrs. Chamberlain was first of all a woman who was run down when she was confined. When I first examined her chest she had signs of bronchial pneumonia. That trouble extending over a good many days — over a fortnight —reduced her general condition considerably. She was then in a likely or favourable condition for infection either from germs very often normally found in the vagina or from, germs causing the chest trouble. That streptococcic germs were present in the vagina or uterus was found by Dr. Frost. Had that infection taken place in an earlier stage Mrs. Chamberlain's uterus would have shown signs of it. Following the case right through, I considered the general infection which eventually lead to her death first showed definitely about the end of August or beginning of September. I prescribed for chest trouble after the first two or three days. Eccles usually makes up the prescriptions. Stock mixtures may have been used. All prescriptions, from the 11th August to the 9th September can be got. Mrs. Chamberlain's name will be on the prescriptions relating to her case. I see objection to the patient nominating the medical man who is to attend the case in the Hospital. Under that arrangement no one man would be responsible for all the patients. Thus if there were one case of septicaemia every man would be blamed for it. There is not enough work at St. Helens for a resident practitioner —nothing like enough. In my opinion, any woman who goes into that Hospital must be attended by the medical man in charge. They can, of course, nominate practitioners for consultation. The medical man attending the family can be present at a confinement, but he cannot interfere unless I ask him. At operations I usually get the anaesthetic administered by the family doctor. Under the rules, another medical man may see the patient, and may disapprove of my treatment, but he cannot interfere. The patient may, of course, be removed from the home by the relatives. Septicaemia can be placed in two classes—localized and general. The former can be diagnozed readily, and, as a rule, treated successfully. There is a well-defined local manifestation of blood-poisoning. I heard the cross-examination of Dr. Briffault as to the methods used in treating general septicaemia. The treatment of general septicaemia can be described as more or less passive. The successful treatment of general septicaemia depends mainly on the patient's power of resistance. Had Mrs. Chamberlain's septicaemia been diagnozed a week earlier than it was we could have done no more than we did to save her life. With the exception of the douching, I agree with Dr. Briffault as to the.course of treatment of general septicaemia. I use the intrauterine douche very sparingly. Once a case of general septicaemia is diagnozed, the best course with regard to the uterus is to do nothing. [Mr. Mays refers to Professor Edgar's "Practice of Obstetrics," cd. 1903, p. 756, 2nd par.] I agree with the statement therein, "It is true, however, that an infectious process not puerperal may become active as a result of parturition." This describes or summarizes what happened in Mrs. Chamberlain's case. The

H.—3lb.

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[t. c. inglis.

seat or origin of the disturbance may have been in the lungs. The patient became septic, among other things, through the state of the lungs, which so reduced her that she became a prey for the germs. I cannot say when the predisposing cause ceases and the septicaemia begins. A rundown condition predisposes to septic infection. I know it is a common method when the high temperature continues to presuppose the case to be one of septicamiia. I did not follow the method in this case. The thoughts of septicaemia were always in my mind, but there were not sufficient signs of it to warrant me in supposing it up till the 28th August. I have had to fight a number of cases of general septicaemia. 1 saw a lot of it in hospital practice. The first and most important thing towards recovery is the resisting-power of the patient. If the resistingpower is not there at the outset there are no means of supplying it. I can conscientiously say that I was entitled to think for a considerable period that Mrs. Chamberlain would rally. Since the opening of St. Helens there have been four cases of general septicaemia. There have been over 1,400 patients in that Hospital. From June, 1906, to November, 1912, there have been 1,407 confinements in the Hospital. There have also been 955 confinements of outpatients, some of which I have attended. The total is thus 2,362 cases. There have only been nine maternal deaths, giving an average of less than o's per cent. There have been seventeen infantile deaths. In addition to the maternal portion of the work, we have trained and qualified forty-three midwives. I produce a table of the results made by me from my annual reports. [Exhibit .] I know cf no maternity hospital in the world where the results are more favourable than are shown at St. Helens. As to the nine deaths in the Hospital, one died from tuberculosis (? sepsis), her debilitated condition making her more liable to infection; two from albuminjuria, one of these being a twin pregnancy which developed uraemia, the other dying from acute and postpartum hemorrhage; one from placenta, paevia; one from concealed hemorrhage, being moribund on admission; one from scarlet-fever and heart-failure; one from, septicaemia; one from the toxaemia of pregnancy; and one from post-partum hemorrhage. The results obtained at St. Helens have to be publicly reported. I think the results at St. Helens are better than the results of private practice. There is evidence of this in the fact that outside practitioners send their bad cases to us. Of the nine deaths, three were moribund on admission. The practice of outside medical men sending their difficult cases to us is growing. I have performed two caesarian operations at St. Helens, and got a good recovery in each case. That is pretty strong proof of the absence of sepsis from the Hospital at the time. Both as to our indoor and outdoor patients, we often have to take them from doubtful or unhealthy surrundings. To the Commissioner.] Rule 12. We have admitted children under this rule. 1 do not know how many. Mr. Mays continued.] It can be fairly said that we have made the best of the building at our disposal. Dr. Valintine has said, " Nothing can alter the fact that an ordinary dwellinghouse, with its narrow passages and many inconveniences, cannot be made into a really suitable hospital." I quite agree with this statement. The present building is quite unsuitable. For maternity purposes the conditions prevailing at St. Helens are absolutely better than those of private practice, be the patients rich or poor. In view of the results, there can be no suggestion of any want of cleanliness or careful administration of the home. There are mothers who have been confined as many as four times in St. Helens, a number who have been there three times, and a very great number who have been confined there twice. I have heard the evidence of Drs. Keller and Briffault as to the quality of the nurses trained at St. Helens. That is the general opinion of the profession on the subject. The members of the profession are always glad to get them. At St. Helens we endeavour to use every means to keep every confinement as natural as possible. A number of confinements take place there which I do not even see. Some few months ago a patient consulted me with regard to St. Helens, and informed me that she had had three previous confinements, aril instrumental, and all the babies died during birth. She told me that she had been advised to have a caesarian section or labour induced before the termination of pregnancy. After examination I decided that she was perfectly able to have a living child. She booked her engagement at St. Helens, and I instructed the Matron that unless something abnormal happened I was not to be called, because I wanted her to do without chloroform and instruments if possible. These instructions were carried out. The woman had a normal confinement, and had a living child. I say that the conditions under which women are confined at St. Helens are vastly superior to the conditions outside, on account of the appliances at hand and the fact that the labour is usually more natural. In my opinion, instruments are often used outside when they are not necessary. They are often used owing to the state of the patient herself. If instruments are used the confinement can be got over much quicker. The instruments are often used in order to save pain to the women. There is not the slightest antagonism that I know of towards the home from the medical profession. In the early stages of the home there was some such antagonism. I would not agree that in lieu of the medical man in charge the Matron should have power to call in a medical man in each case. As to the medical man being in outside practice as a surgeon, I say that the surgeon is trained more to cope with infection than the physician; he attends practically no infectious work, and he is capable of performing the operations that arise or may arise during confinements. The physician in outside practice is much more in contact with infectious cases, and would probably prove a greater source of danger than a surgeon. Before the advent of St. Helens confinement cases here requiring operation were always put in the Hospital surgical wards as apart from the medioal wards. I think it would be impossible to admit cases before the confinement has started, except in special cases which need treatment or watching before the confinement. These special cases are admitted at such earlier period as is thought necessary. They are watched and treated. The objection to admitting patients before the actual commencement is due to the fact that the actual time of labour is a very uncertain date to go on. We could not take anything like the number of patients that we do at present, as the beds would be filled with patients waiting. I do not think that the Hospital should be re-established as an

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adjunct to the General Hospital. I was for many years a resident at the Auckland Hospital. Personally, I think that the Hospital is better under the control of the Department than under the control of the Board. I think the General Hospital is too big already. Compared with the General Hospital, the working of St. Helens has been very smooth and economical. I think the utmost value has been obtained by the taxpayer from the funds available. I have no reason to think that cases of sepsis have occurred at the home through it being of wood, and there being a possibility of septic-germs being fostered in the scrim and paper. Mr duty is to attend patients inside when called on and patients outside when called on. The submatron goes to outside cases. She does not attend to the after-treatment. I make my annual report from the case-books. Ihey give a fair, concise, and accurate report of each case. 1 have looked up in them cases that I have attended myself, and I have no fault to find with the entries. As to case-books, I should make a very big distinction between a maternity hospital and a general hospital. In a maternity hospital I say that the case should be written up on the termination of the case. In the Women's Hospital, Melbourne, the case-book is made up in that way. That is supposed to be the easiest way, and is quite a satisfactory way. It is generally made up from the notes kept by the Matron and nurses. The nurses should keep note-books in each case. I do not know how the case-book is kept at the Mental Hospital. In the General Hospital the case is written up as it arises, in some cases from day to day, or once or twice a week. The case-book gives me a synopsis of what has happened. I know of some private maternity homes in Auckland. There are a good number. They are registered under the Hospital and Charitable Aid Act. I first suspected lung trouble in Mrs. Chamberlain on the 13th August. There was no test made of her sputum. There was very little sputum. In this class of case there is practically none. I do not think there was sufficient to make a test. I did rot think it necessary to make a test. Cross-examined by Mr. Skelton.] I have never had any appointment to a maternity hospital before St. Helens except an acting appointment. That was at Melbourne, where I relieved on two or three occasions for a short time. 1 specialized in obstetrics and gynaecology. lam not acquainted with the proceedings of the Central Midwives Board in London. I have not seen their rules. While acting at Melbourne I was resident. The institution is large, accommodating somewhere about fifty cases. I have seen ten cases of labour going on at the same time. When a patient in labour is admitted to a home she is usually examined to see the state of the labour. If there is time she is given a bath, not necessarily antiseptic. I think it is advisable that an antiseptic bath should be given in every case, with exceptions. I do not think, personally, that there is much good in antiseptic baths, though they might be very good as routine treatment. 1 think soap and water will do as much good as the antiseptic bath in most instances. I do not think it is necessary to treat every patient coming in to the home as if she was septic. I do not think it possible to treat every woman coming in without great discomfort so as to lessen the risk of sepsis. It is possible to do great harm by the too free use of antiseptics, especially in maternity work. The Hospital does not work under the " Rules for the Guidance of Midwives." We work under the "Rules for St. Helens Homes" and the " Rules for State Maternity Hospitals." In my opinion the words in Rule 35 apply only to cases under Rule 34. I have no notes made by myself relative to the case of Mrs. Chamberlain. I know that I visited Mis. Chamberlain every time I visited the Hospital while she was there, with ene exception —the day I did the csesarian section. I do not visit every patient in the home on every visit I pay there. I have heard the statement that I did not visit Mrs. Chamberlain till the third day after her confinement. That is absolutely incorrect. I spoke to her on my first visit. The Matron reported to me on the occasion of my first visit to Mrs. Chamberlain that she had a temperature. To the best of my belief, that was the first time I had heard of Mrs. Chamberlain's case. I do not remember the time on the 12th August that I saw Mrs. Chamberlain. That is all that I remember the Matron reported to me —that she had a temperature. I made an examination of the perinseum on, I think, the 16th August. The Matron reported the temperature the first day, and from that on I watched the case myself. I knew on the 12th that the patient had a ruptured perinseum. The Matron told me on the 12th about the confinement. She said the patient had a normal confinement. I asked her if the afterbirth was all right, and so on, and whether there was any tear. I did not regard the tear as an abnormality. A rupture to a slight degree is not considered in well-conducted homes to be a thing requiring the- services of a practitioner. I did not examine the perinseum on the 12th. I was told two stitches had been put in. I did not then nor do I now 7 think it advisable to have inspected the perinaeum. I asked the patient if she was comfortable, and she said " Yes." I consider the rupture was one of the first degree. I first saw it on the 16th, I think —the fifth day of the confinement. The actual day of confinement is not counted. A tear of the first degree is one involving the skin and mucous membrane of the perinseum, often only the fourchette. The tear is usually an inch to an inch and a quarter. A tear of the second degree is through the perinseum-body. In Mrs. Chamberlain's case the perinseum was a normal one of 2J in. to 3 in. The third degree extends through to the rectum. On the 12th Mrs. Chamberlain had a cough, and she looked as if she had done a good bit of hard work. She was a medium-sized woman. She did not look 12 stone. The fact that the woman was suffering from a ruptured perinseum of the first degree did not demand my attention. Had I seen in the case-book that there was a rupture of the second degree I would have asked the Matron about it. I would have asked if it were all right if she had said there was a rupture of the first degree. On the 11th the Matron would have a very fair opportunity of deciding to what degree the rupture of the perinseum belonged. The rupture heals up as the days go on. I have not known the Matron to make many mistakes. I have a general idea of how many perinseums she has sutured. There are not a great many. In the year ending the 31st March, 1912, there were eleven of first degree and nineteen second degree. I cannot say how many of those of the second degree were sutured by the Matron. I told the Matron that she could suture in

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slight tears of the perinaeum. I did not define the degree. I have not found the Matron prone to make mistakes about these ruptures. If the Matron characterized the rupture as one of the second degree she might be right. When I saw the rupture on the 16th or 17th it was in a state of healing. It would have been completely healed about the Bth or 9th day —that is, about the 18th or 19th. The Matron could say better than I can to what degree the rupture belonged. I prescribed no special treatment on the 12th. A day or two later I prescribed something for her chest. I cannot say what it was. If it was a stock mixture I would simply tell the Matron ; if it were a prescription it would be made up at Eccles's. I examined Mrs. Chamberlain thoroughly to find out what was wrong with her. That was, I think, on the 13th. Her temperature was then 102. I did not then examine where the sutures had been put in. I examined her abdomen and chest, and inquired into her history. I sounded her. She told me she had a cough, and that she had had it for some time. At that time I did not look on it as a matter needing to be inquired into. I could not say on what day she was moved into a room by herself. I do not know when the stitches were removed. I did not remove them. I never do. I know they were not there on the day before she went into the isolation ward. There is a general instruction that any patient with a temperature has a nurse to herself. I do not know that a nurse was instructed not to watch any other patient than Mrs. Chamberlain. It was about the 16th or 1 7th that I made an examination of the uterus and other parts. I have no doubt that I knew on the 16th that her temperature was 103. I looked at the chart. It was an up-and-down temperature. The temperature-chart did not tell me that the case was becoming very serious; that was quite consistent with the lung condition. I examined the patient again about the 16th or 17th. There was some flatulence, but there was not what I would call a distended abdomen. The lochia was normal. Mrs. Hunt might have been in just after the bowels had acted, and there may have been a smell in the room. I thought of the possibility of septicaemia when I notified the Health Department. I was taking precautions all the time. There were no symptoms of septicaemia, and I was treating her for her chest condition. I do not think the throbbing at the site of the stitches and the distended abdomen (if present) would necessarily indicate sepsis. You get a throbbing pain at any wound without sepsis. If the conditions of throbbing, distended abdomen, and offensive smell existed, I would suspect septicemia. In this case we had everything to account for the temperature, and there were no signs of sepsis. Mrs. Chamberlain suffered more or less from flatulence right through from the start. I noticed it when I made the examination on the 16th or 17th. A distended abdomen is one of the conditions of septicannia. The distension noticed by the women was not the distension of septicaemia. There was no distension from flatulence to any extent. I say that so far as it appeared to me it was normal. The woman had not a flat abdomen. The abdomen might be described as normal after any confinement. The abdomen distended in the last few days, beginning about the 4th or sth September. The stomach was very little distended by the flatulence. I could not explain to you the difference between distension due to flatulence and that due to septicaemia. One learns it from one's training. Adjourned to 24th. Friday, 24th January, 1913. Tracy Russell Inglis, cross-examination continued. I should think I first mentioned my suspicions that Mrs. Chamberlain was developing an infection somewhere about the end of August —when I was sick. I was seven days off duty—from the 28th August to the 3rd September. I paid one visit to the Hospital during that time. I paid a number of visits on the 28th —none on the 29th. Dr. Goldstein visited St. Helens. I talked the case over with Dr. Goldstein while I was ill. The question of septic trouble was discussed. I. was looking for sepsis the whole case through. It was not there. I had a suspicion when I was taken ill that septic trouble might be developing. My suspicions first developed when I notified the Health Department —not sooner. 1 was only suspicious on the 28th August. The patient was at that time isolated. She was isolated on the 24th. There was no suspicion then. As there was a temperature, I thought it best to be on the safe side, and have a trained nurse, and isolate the patient. To the best of my ability it was the morning of the 29fh when I discussed the question with Dr. Goldstein. 1 am on the honorary staff of the Auckland Hospital. I cannot say how many cases I was attending there between the 11th and the 28th August. I pay two official visits per week, and do one morning's operating. I could not say how many cases I saw. I can give no idea. St. Helens is a small hospital, and we have there very few abnormal cases, so that I remember every detail of any that are abnormal. No record is kept of my visits to any particular case at the Auckland Hospital. Ido not remember any specially abnormal cases that I was attending at the Auckland Hospital from the 11th to the 18th August. I say that I do not remember any. I will not swear that there were none. Without further data to go on, I could not say how many of the cases in the Auckland Hospital during that week, from the 11th to the 18th August, showed any abnormality. 1 could not tell without reference to my books how many cases I was attending in my private practice during that week. There were*certainly several abnormal cases in my private practice during that period—about four or five—not more than ten or twelve or less than four or five. Without reference to my books, I cannot say -what these patients were suffering from. I could not have given particulars as to Mrs. Chamberlain's case without my books. There is no writing by me further than my own books relating to Mrs. Chamberlain's case. After mentioning Mrs. Chamberlain's, case _to Dr. Goldstein I next mentioned it on the Ist September, when there was a consultation with Dr. Lindsay. I fix the facts as to Mrs. Chamberlain partly from the notes I made in my books and partly from my own recollection. -I think Mr. Chamberlain was the next one I discussed

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the case with. That was on the 4th September. I may have mentioned the case again to Dr. Goldstein between the Ist and the 4th September. If you include the Matron, I say that I inquired of the Matron every day as to the case by telephone while I was ill. I could not fix the date I first communicated my suspicions to the Matron that septicaemia might be setting in. I discussed it so often. I cannot fix the date on which I first.mentioned my suspicions of septicaemia in Mrs. Chamberlain's case to the Matron. I cannot say how many times before the sth September I discussed my suspicions of septicaemia with the Matron. I produce a chart re Mrs. Porch's case just received by me from the General Hospital. [Exhibit No. 6.] Ido not know if it is a copy or the original. I did not visit Mrs. Chamberlain every day after the 12th. I cannot tell without reference to my ledger how many days I visited her between the 12th and 28th, both inclusive. The 13th was the date of my second visit to Mrs. Chamberlain. The next was the 16th. My visit on the 12th lasted about four or five minutes; that on the 13th, I should think, about five minutes. It may have been more than five. I first made a thorough examination of Mrs. Chamberlain on the 13th. I made a careful examination every time I saw the patient. It was an examination such as the condition of the patient demanded. On some days I examined her more thoroughly than others. I made the necessary careful examination every time I saw the patient. In view of my statement on page 119, that on that occasion I examined her very carefully, I say that I made on each occasion the necessary careful examination. I examined her carefully on the 21st. On that day I made possibly a more careful examination. I cannot pull the patients about every day. When I said (page 43) that just about that time I examined her very carefully I meant that I made perhaps a more elaborate examination as to the condition of the patient than was necessary. I fix dates to a certain extent by other things that happened about the same time. I remember the 21st from the caesarian section on the 20th. When I said (page 43) that just about that time I examined her very carefully I meant on or about the 21st. I swear I made the examination on the 21st. When I said " Just about that time," I meant that I examined her on the 21st. When I said "On or about the 21st," just now, I meant that I did it on the 21st, because I fixed it from the cses-arian section, which I did on the 20th. I considered that "On or about the 21st " meant on the 21st. I now swear definitely that I made the examination on the 21st. By the words " Just about that time " (page 43), I may have been lax in not saying, " On that particular day." I am certain as to the exact time. "Just about that time" was correct as far as I then knew. " Just about that time I examined her very carefully " means that on the 21st I examined her at St. Helens. There is no possible doubt about the date of the careful examination. I could not say I had thought over it, particularly when I was giving my evidence. I have thought over it since. My evidence as to the careful examination on the 21st is to the best of my knowledge quite correct. I found the perfect involution of the uterus as the result of my very careful examination on the 21st. The uterus had involuted perfectly on the 21st, and when I examined her again on the 23rd or 24th the involution was still going on perfectly. I swear positively that I made a very careful examination on the 21st. In my examination-in-chief I meant to infer that I made two examinations between the 20th and 25th. I remember examining her the day she was transferred to the isolation ward. I do not think I was asked if I made two examinations between the 20th and 25th. I do not think it was my intention to lead you to believe that I saw the patient on the 21st, but the careful examination was made between the 20th and the 25th, on a day which I could not exactly fix. The involution of the uterus was going on properly on the 21st. I did not give any special instructions to the Matron when I first mentioned to her my suspicions of septicaemia as to the treatment of Mrs. Chamberlain. A trained nurse was in attendance then. To the best of my knowledge the trained nurse came on when Mrs. Chamberlain was removed to the isolation ward. I cannot fix the date I first mentioned any suspicion of infection to the Matron. It may have been somewhere about the end of August. I discussed it so frequently that I cannot fix the date. I had suspicions of septicaemia during the end of August, but I would not say they were very grave suspicions. I could not say if they were slight suspicions. I could not say as to the graveness of the suspicions. I think the Matron mentioned that Mr. Chamberlain was getting anxious about his wife on the day he came to see me. I think that was the day on which she was removed to the isolation ward. That is to the best of my knowledge. The Matron never reported to me that Chamberlain threatened to see a solicitor to see if he could not get some action taken. The course of treatment would be very much the same for both troubles —septicaemia and chest trouble. I kept on the treatment on general lines, making no special treatment with reference to septicaemia. That would not have been justified in view of the fact that I had only suspicion then. For the bronchial pneumonia, as far as I know, I prescribed for the cough. As soon as I got the report from Dr. Frost as to the infection I gave her vaccine. She had salines some timie. I do not remember when they were given. I cannot give anything more definite than I have given as to when I started a special treatment against septicaemia. I prescribed the salines. They are usually injected into the rectum. Their object is to stimulate the patient, dilute any poison that might be in the blood. I could not say definitely if the salines were given before Dr. Frost's report. There would be a note in the nurses' reportbook as to the salines —not necessarily on the charts. A saline injection is used for a great many things. The chart shows that salines were administered on the 6th and 7th. When I got' Dr. Frost's report I started the special treatment for septicaemia. I gave her vaccine. The general treatment was continued. About that time or just after, I think, she was having salines. As her pulse required it she had digitalis. I think she had strychnine once or twice. The fact that her temperature was 101 on the 12th was not sufficient to warn me that there was danger of septicaemia. The fact that it was 102 on the 13th and 103 on the 16th was sufficient to warn me of septicemia. I have never seen the work " Dorland's Manual of Obstetrics." To the Comniisioner.] I heard Dr. Briffault's evidence as to the temperatures indicating that the case wanted medical attention. I agree with his evidence on the matter on page 39.

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Cross-examination continued.] Any rise in temperature over 99 would make one look for something in the patient to warrant it. One would look for septicaemia among other things. There is no special temperature absolutely characteristic of sepsis. There is nothing significant in the fact that the temperature was 101 on the second day. The rise in temperature would have been sufficient to notify me of the beginning of septic changes had there been no other causes to account for it. Up to about the end of August (1 could not say the date) I was sure the high temperature was due to bronchial pneumonia. Up to that time there was absolutely no sign of septic trouble. In the latter part of August I had suspicion that sepsis was developing. A temperature of over 99 would demand attention, but it does not of itself indicate sepsis, and I would watch it carefully. From the 13th to the 19th there was not much change in the patient's outward appearance. When I saw her on the 12th she looked a run-down woman. I cannot . describe her any more. I am not good at word-descriptions. She did not look very ill, but fagged and worn out. I do not think she complained of her sleep being bad. The sleep shown on the chart is not very much at night, but there was probably sleep during the day. The temperature on the chart for the first week is an up-and-down one. I .had the condition of the lungs, and that quite accounted for the temperature. There was the fact that the uterus was involuting properly, that the lochia was normal, that there was no particular pain in the abdomen, and that there was no particular distension. I set it all down to bronchial pneumonia. There were patches of consolidation in the lungs. There is not always sputum, and I think she always told me there was not any. I did not think it necessary to ask the nurses on the subject. I got no hint at any time that Chamberlain was not satisfied with the treatment his wife was getitng. Husbands often talk over the cases with me. It occurred to me when he came that he was anxious about his wife. After talking with him he went away quite satisfied. To the Commissioner.] I was not in any way annoyed about Dr. Brockway ringing me up on the subject. This was a further indication that Chamberlain was anxious. I say positively that I never understood from him that he was dissatisfied with the way in which his wife was being treated. To Mr. Skelton.] Chamberlain said something about wanting to know about his wife. He may have said that she had not got up in the usual time. He left me on the night of the 24th telling me that he was perfectly satisfied. I do not know that it was the next morning that Dr. Brockway rung me up. Dr. Brockway's conversation did not lead me absolutely to think he wanted to see the patient. He did not ask definitely to see her. Ido not think Dr. Brockway said, " Chamberlain did not seem satisfied with any report he could get from the Hospital as to his wife's condition." That might have been stated. I cannot remember the exact words. Dr. Brockway did not state that Chamberlain wished him to go up and see his wife and give him his opinion as to her condition. 1 have no recollection of him saying such a thing. If he said it I think I would remember it. He made no distinct request to be allowed to go to the Hospital. He asked the rules governing- the question. Chamberlain came to me later, and suggested to me Dr. Brockway's name as a consultant. I did not say that I would not give Dr. Brockway admittance. I said I wuold not consult with him. It is absolutely incorrect that I gave a reason that Dr. Brockway did not belong to the British Medical Association. I have not refused to meet another medical man not a member of the British Medical Association for the reason that he was not a member of the British Medical Association. I have not refused Dr. Florence Keller for that reason. I have held office in Auckland in the British Medical Association. I have been president, vice-president, secretary, and a member of the executive. There is no rule that we shall not meet or consult professionally with medical men who are not members of the British Medical Association. Dr. Dudley or Dr. Carrick Robertson is at present secretary of the British Medical Association in Auckland. The British Medical Association has printed rules. We have no rules by which we are pledged not to meet professionally or consult with other medical men who arc not members of the British Medical Association for the reason that they are not members of the British Medical Association. Dr. Pabst is president of the British Medical Association here. T would not have to get the permission of the committee before consulting with a medical man not a member of the British Medical Association for the reason that lie is not a member thereof. There is no rule to the effect that we must not meet with or consult professionally medical men who are members of lodges or attached thereto, or with homoepaths or connected therewith. There was a dispute some years ago between the British Medical Association and some friendly societies here. As, a result they brought some other medical men out, and we decided not to consult with them or meet them professionally except in emergencies. So far as I know, that does not apply to public appointments —that is, lam not affected in any way by the rule except in my private practice. Dr. Brockway is connected with friendly societies. He comes under the ban, and for that reason —that is, that he was imported from America by the friendly societies to take office against us. I think in the early days of St. Helens I had a consultation with Dr. Mackellar, who is not a member of the British Medical Association. I have had consultations with Dr. Makgill, who is not a member. He is not in private practice. I. think it was about the 4th that I told Chamberlain about my suspicion of septicaemia—it was, any way, on the day I told him about the blood-test being taken. I only suspected septicaemia on the 28th August. I did not alter my report to indicate whether it existed or was suspected to exist.. I left no message on the 28th with the Matron that Chamberlain was to be informed that his wife was in a dangerous condition. I do not think I said she was in a dangerous condition. You said that. Dr. Frost took the blood-test on the 3rd. I suggested that she should make an examination. Dr. Frost took the blood from the patient herself. I do not think the test would have been any good earlier. As it turned out, it was not much good then. Dr. Frost's report was a verbal one, on the telephone. The test was not of very much value. Had the blood-culture been virulent then it would have been of very much value. Dr. Frost reported by telephone that the blood-culture was sterile. The Matron told

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me that Chamberlain was anxious. I could not say when that was, but I would not deny that it was before the blod-test was taken. Ido not remember her saying that he was there every night. She may have. I was not induced to get the blood-test by the fact that Chamberlain was bestirring himself. The condition of streptococci in the uterus may have existed for three or four days—not more —before Dr. Frost's examination of the swab. Luncheon adjournment. To Mr. Skelton.] I remember Mrs. Chamberlain, but I do not know how to describe her further than I have done. .1 am not good at descriptions. She was of a sallow appearance. I would not say her cheeks were hollow, though they were not fat. She was certainly not hollow-eyed. I could not say whether she was particularly dark under the eyes or not. There were the usual lines of expression about her face. She looked worn out. I would not say she looked ill. Dr. Frost was instructed as to the swab on the 3rd. I did not think there was any necessity for instructing her earlier. The material for the test could have been obtained from the patient at an earlier date. There was nothing to prevent its being taken from the patient on the 24th August. Mrs. Chamberlain's case has been a matter of communication between me and the Department. I cannot say if I made a special report in writing about the case. I do not think I did. On the 28th 'August I made the report to the Health Office. I did not, between the 28th August and 2nd September, take any steps to inform Chamberlain that I had suspicions of septicaemia. I think it was the 4th" when I informed Chamberlain that I thought his wife had a general infection. I do not think I ever told him how his wife's pulse was. If her pulse was 128 on the 17th I do not think that an alarmingcondition —not on one occasion. I cannot say if her pulse went up or down after that. It went up at some time or other after that. That the pulse went up to 130 next clay would bear me out in my supposition that it was bronchial pneumonia, I do not think it showed a remarkable state of things. I know she had a high pulse, but I thought that consistent with her general condition. Her condition did not at that time excite me. It is certainly not a fact that a patient who leaches 140 never recovers. I have seen them recover after 150. That Mrs. Chamberlain's pulse reached 150 on the 2nd September would depend as to whether it was alarming or not on the circumstances under which it was taken. The use of an enema will send a pulse up; any excitement will do the same; any vomiting. There are hundreds of things that will excite a pulse. I cannot give you any idea as to when I put the notice to the Health Department into the post. I could not tell you exactly when I wrote it. I think it was the night when I went to bed ill. It was written on the day it was dated. I do not know if it was delayed in transit, I cannot account for the delay in the notice reaching the Health Department, I did not write the notices re Mrs. Chamberlain and Mrs. Porteous together. Nothing was said to me as to the late receipt of the notice. I left a message for Dr. Valintine, and reported the matter later on to Dr. Makgill—that was about Mrs. Chamberlain's case. I am hazy whether or not I discussed the case with Dr. Valintine. I told Dr. Makgill the history of the case much as I have reported it here. I might have told them that that was what I was told—that was, that Mrs. Chamberlain had been nursing- her mother, who had an ulcerated or septic kg. I gave Dr. Makgill a resume of Mrs. Chamberlain's case much as I have given it here. 1 may have said to him something about her nursing her mother. I cannot say when this was. It was in Dr. Makgill's office. I have no date to assist me in fixing the incident. I suppose Mrs. Chamberlain's case was an unusual case. It was an unusual case. There was nothing important about that to fix it. [Mr. Skelton puts in letter dated 28th October, 1912, from Mr. Bradney, M.P., to Mrs. Nicol, in reply to a letter received by him from Mrs. Nicol re Mrs. Chamberlain, and enclosing a report on the case signed by Dr. Valintine, dated 4th October. [Exhibit No. 25.] Mr. Skelton.] Were you ever called upon by an officer of the Department, or the Minister, oi any other person to report on the ease of Mrs. Chamberlain, either during her illness or after her death?—l was asked to see Dr. Makgill at the Health Office. Were you asked verbally or in writing?—l fancy it was part of a letter to the Matron at the Hospital. lam not sure of this; it might have been a separate circular to myself. Can you produce any communications of any kind between yourself and the Department relating to Mrs. Chamberlain's illness and death?—l do not think so. Was there any such communication? —I saw something, but I think it was addressed to the Matron. To Mr. Skelton.] As to Dr. Valintine's report, I agree with the first paragraph. Mrs. Chamberlain had a cold. She had a bad cough is the way I would have reported it. I think the state might have been described as a bad cold and cough, though that is not as I would have described it. 1 would simply have said she had a bad cough. A cold may last for a long time. I agree that her temperature rose immediately after a very quick confinement. I would say that twenty-two hours thirty minutes was a quick confinement for a first. I would not have described it as a quick confinement. The figures in the case-book showing the time from the end of the first stage to the end of the second stage is the best guide as to whether or not it is a quick confinement, assuming the figures to be correct, I see that the case of Mrs. Scrimshaw (1335) shows end of first stage 11.25 p.m., and end of second stage 12.15 a.m. The case of Eliza Leroy (1361) : End of first stage 1.10 p.m., and end of second stage 1.50 p.m Case 1365 : End of first stage 6 p.m., and end of second 8.20 p.m. Case 1374 : End of first stage 12.10 p.m., end of second stage 12.40 p.m. Case 1378 : End of first stage 10.20 a.m., end of second stage 11.15 a.m. These were all considerably quicker than Mrs. Chamberlain's, but you cannot depend on those times. No one can tell you exactly when the first stage starts. I did not throughout base my opinion more on septicaemia than on bronchial pneumonia. As to the statement in the report of Dr. Valintine that Mrs. Chamberlain was removed to the isolation ward and a private nurse specially engaged to attend her as the hospital nurses were very busy, I say that that was not my reason—that the hospital nurses were very busy. My

H.—3lb.

52

[t. c. inglis.

reason was that I considered that a general trained nurse, apart from a maternity nurse, was the better for the patient. That was one of my reasons for removing the patient into the isolation ward; the other was that in any case of a sustained temperature I thought it better for the other patients to be on the safe side, not necessarily because high temperature necessarily means sepsis. When I ordered her removal I felt pretty sure she had not got sepsis, but as there was a chance of it I thought it better to remove her. I had diagnosed the case as one of bronchial pneumonia. About the end of August or beginning of September I thought there were signs of general infection. 1 do not know the nurse in charge in the isolation ward. I would not consider the fact that the Matron stitched the perinaeum as a surgical operation. I do not agree , that, strictly speaking, it is. I think the stitching of the perinaeum is one of the ordinary duties of a trained nurse. I think it might be put down as an ordinary duty of a trained nurse in a certain position—that as a Matron of a maternity hospital. I do not agree with Dr. Brifiault that the stitching of the perinseum is a surgical operation. It is an ordinary duty of a trained nurse to stitch ruptures of the perinaeum of the second degree in some cases, as Matron of a hospital. If it were a slight tear of the second degree it would be the ordinary duty of a trained nurse to stitch it — that is, if it went just into the muscles. That would be technically a tear of the second degree, yet it would be a very minor tear. Exactly the same would apply if the Matron were attending a case outside the Hospital. Personally, I would not prohibit mid wives suturing in outside cases, though it is a practice not generally approved. I think an ordinary trained nurse would regard it as an ordinary duty to stitch a ruptured perinaeum. In certain cases it usually is one of the ordinary duties of an ordinary trained nurse to stitch a ruptured perinseum. 1 say it is the ordinary duty of an ordinary trained nurse in an institution to stitch ruptured perinseums, but not outside except in cases of emergency. The mere fact that the patient on whom was performed the csesarian section escaped infection does not prove that there was no sepsis in the Hospital, but it is in favour of that view. I told Chamberlain about the 4th September that I thought his wife had some general infection. It was after I had the first part of Dr. Frost's report. I would allow the Matron to stitch perinaeums which were ruptured to the first degree and in certain cases the second degree. A rupture of the second degree includes a tear through or partly through the perinoeum-body. It may extend up to the sphincter ani. The first degree is through the skin and mucous membrane. In my opinion, the sepsis came either from germs found very often normally in the vagina or it may have been an auto-infection from the lungs. I should think Mrs. Chamberlain had been a strong healthy girl. I think she was run down when she came to the Hospital. 1 would not have classified her as a particularly fine stamp of woman. I never saw her out of bed. She looked in bed to be nothing out of the common. I found nothing wrong about her except that she was run down. I would not have said she had good powers of resistance when I saw her on the 13th. I diagnosed her case as one of bronchial pneumonia. That from fine crepitations in various parts of her lungs, a temperature, and a cough, and no other symptoms to be found anywhere else to account for these things. [Further cross-examination deferred.] To the Commissioner.] I compiled the mortality and birth return that has been put in. I cannot say as to how many cases I attended outside the home. The submatron would attend the delivery outside the home. She is the only person entitled to do so. Of the nine deaths, none were outside the Hospital. It is possible that one was outside. Dr. Goldstein was responsible for Mrs. Chamberlain's treatment while 1 was absent through illness. He would have to rely mainly on my verbal history of the case when he took it up—on that and on the chart. When I resumed responsibility Dr. Goldstein would report to me as to what had been done, so that I could take the case up where he left it off. I saw Dr. Goldstein every day, as a matter of fact. Dr. Goldstein had a consultation with Dr. Lindsay on the Ist September while I was ill. I suggested that consultation. I did so because I thought the patient's condition demanded it, and I would like another opinion as well. I thought she was developing sepsis, and I wanted an opinion to confirm that. Dr. Lindsay would learn the history of the case from Dr. Goldstein. Dr. Goldstein would tell Dr. Lindsay what I had told him and what he knew himself. I was told that Dr. Lindsay agreed with my opinion that there was sepsis intervening on bronchial pneumonia. I did not see Dr. Lindsay personally myself. Assuming that I have power to get help from other practitioners, I would select the practitioner to be called in. I would not consult the Matron as to who should be called in. I heard a long time after Mrs. Chamberlain's death that there was going to be trouble about the case. I cannot remember sending in any report by telegram or letter on the case. I have discussed Mrs. Chamberlain's case with the Matron since there were rumours of trouble. Ido not know if the Matron reported to Wellington on the case. Ido not remember if I reported. Ido not know where the facts on which Dr. Valintine's report is based were got. Cross-examined by Mrs. Nicol.~\ In the General Hospital certain day reports are destroyed after a certain time. I think they are kept for about two years in the General Hospital. I think Dr. Goldstein was the most capable man I could have brought into the home for workingmen's.wives. It is true that the septicaemia-germs do get into the blood-germs. I know how a blood-test is taken, but it is not my special work. I leave it for a bacteriologist. I say that, as far as possible, nature should have her own way with regard to the labour. My private practice takes up a lot of my time. An instrumental labour is always quicker than an ordinary one. There is not an extra fee for an instrumental labour in an ordinary private case. I was present at the majority of my private confinements. St. Helens nurses know exactly when to send for me. I have never heard of bleeding as a treatment for septicaemia. It is certainly not a modern treatment. I think one nurse was quite sufficient in Mrs. Chamberlain's case. Sleep is necessary to the patients if they can get it. There was no necessity for a night and a day nurse. There are hours of duty for the regular nurses. The Matron regulates them. I think the nurses trained at St. Helens are quite efficient as maternity nurses.

T. B. INGLIS.

53

H.—3lb.

It is quite possible that Mrs. Porch and Mrs. Brown were in the one room next to the one which Mrs. Chamberlain used to be in. The patients in the Hospital were properly protected after the case of speticaemia there. Every known precaution was taken to prevent the infection spreading. I know that several rooms were fumigated, and that all possible inquiries were made to ascertain the origin of the infection. I conferred with the District Health Officer. He was satisfied with everything I had done. I instructed the Matron verbally as to the disinfecting and fumigation. I assumed it was done. The Matron told me how the isolation cottage was done. It was scrubbed down with Jeyes fluid by the gardener. Adjourned to 27th, at 10 a.m.

Monday, 27th January, 1913. [Further complaint from W. 0. Stevenson, dated the 26th January, 1913, railway porter, Pukekohe, read.] Tracy Russell Inglis, recalled, saith. Gross-examined by Mrs. Nicol continued.] Re Mrs. Porch's chart : I did not see Mrs. Porch's chart that day. The one put in the other day was the one sent down from the General Hospital. When Mrs. Porch was sent there I asked the Matron to send the chart with her. There are two charts produced. I cannot say which is the original. I do not know that the chart was copied. The chart came here from the General Hospital in the envelope I opened in the box here. I rang up the Hospital the night before, and asked them to send the chart down here. The chart I hold in my hand is the chart I got from the Hospital. I telephoned to the senior resident asking him to send down here Mrs. Porch's chart that was sent with her to the Hospital from St. Helens. With regard to the other chart marked D, I know nothing about it. Ido not know where it came from. I cannot say that the other chart is the original. I think it is. I cannot identify either of these charts as the original chart kept at St. Helens. Since the commencement of this inquiry 1 have done nothing in connection with Mrs. Porch's chart at the General Hospital further than to telephone as I have stated. It is quite possible that Dr. Goldstein is junior to me. The fact that Dr. Brockway is junior was only one of the three reasons for refusing to consult with him. In most cases it is not stated in the death notice in the newspapers that the patient died at St. Helens. I was asked in connection with the first death there by the relatives if they should put in the papers the fact that the patient died at St. Helens. 1 said it would perhaps be better not, as it might have a prejudicial effect on intending patients. I remember you asking for an inquiry once. I do not know when it was. You have worried St. Helens ever since it was opened. I cannot say that the fact that a death takes place at St. Helens is noted on the certificate. I may put only Pitt Street, as it is my custom in my certificates to put the name of the street. The relatives can put in what they like in the newspapers. I was appointed by Mr. Seddon. I do not know what Dr. Valintine had to do with the appointment. I think Dr. Mason was Chief Health Officer when 1 was appointed. There is not as much danger of sepsis entering the body from one small suture as from three or four. I think the bigger the wound the more chance of the sepsis entering. Blood-poisoning can be got from a prick of a pin, but it is more likely from several pricks. Women have remained with small tears and with tears of the uterus without them being stitched. A tear in the uterus is practically never stitched at the time. I think if there is a small tear it is better to have it attended to at the time. I think it is much better to have the sutures put in at the time than to wait for me to come along. I refer to the case of small tears. There is more danger from leaving them unsutured than suturing it at the time. I asked that the chart that was being sent down should be the one sent to the General Hospital with Mrs. Porch. To the Commissioner.] I never interfere with the discharge of patients unless they are ill. I do not give the Matron authority to discharge every patient. She has a general authority. In all cases of doubt as to the patient's fitness for discharge the Matron asks me, and I decide. The same applies to infants. No record is kept to my knowledge of the discharge of patients. Instructions on the subject are verbal. [Further cross-examination by Mr. Skelton postponed.] Herbert Myer Goldstein, recalled, saith. To Mr. Mays.] I first saw Mrs. Chamberlain on the 28th August, at Dr. Inglis's request. Dr. Inglis became ill that day. It was in the afternoon that I saw the patient. I only saw the patient generally that day. I was to take over the work of the home while Dr. Inglis was ill. I saw the patient again on the morning of the 29th August. I then examined her carefully. She was suffering from fever, which might have been due to anything, with rapid pulse and rapid respiration. The chest showed symptoms of lung trouble. I examined the genital organs. The patient was very easy to examine there. There was no pain or tenderness. There was no evidence of local trouble in the genital regions. I saw the patient again on the 30th. She was then in the isolation ward. I did not then make a close examination. The condition of the patient was much the same as on the previous day. I examined her carefully on the 31st August. Her general condition was then much the same, but the signs of lung trouble had diminished. Up to the 31st there was nothing sufficiently definite about the patient's condition to justify me in saying absolutely that it was a case of septicaemia. I saw the patient again on the Ist September —this time with Dr. Lindsay. I used to see Dr. Inglis every afternoon or evening. I told him what was going on at St. Helens. On the 31st August I told him that with reference to Mrs. Chamberlain I began to suspect that there might be some other trouble. We decided that I had better have a consultation with some one else. Dr. Lindsay and I came to the conclusion that there might be septicaemia then, but there was no definite proof of it.

H.—3lb.

54

[H. M. GOLDSTEIN.

Later in the day I informed Dr. Inglis of our conclusion. I saw Mrs. Chamberlain on the 2nd September. She was much worse that day. Dr. Inglis resumed charge on the 3rd. Dr. Inglis gave me a history of the case, and his views on it, when I took it over. I know what his diagnosis was up to about the 28th. Dr. Inglis's diagnosis up to that point would be justified from the history of the case and the chart. I agree that Mrs. Chamberlain's chart is not inconsistent with chest troubles such as bronchial pneumonia. To the Commissioner.] It is also consistent with septic trouble. At the beginning of septic trouble one really cannot do very much. Sepsis would be discovered by an examination of the blood and a swab from the genital canal. This would be done by a bacteriologist, It is not usual to,test for septicaemia in the case of a woman after her confinement till one has reason to suspect it to be present. To Mr. Mays.] No doctor would be likely to test early for septicaemia if he found what he regarded as sufficient cause for the high temperature. If one has reason to suspect septicaemia he would look out for the general health of the patient, with the idea of assisting them in their powers of resistance. If one were absolutely certain of the type of infection, one would then give an injection. The latter is a special treatment. This varies with the various bacteria that give rise to the trouble. Usually the first sign of septic trouble appears on the third day. I attach no importance in the present case to a high temperature on the first day. That is fairly common. Very frequently the blood-test is negative till the disease is sufficiently developed to be diagnozed, and, to my mind, the swab is absolutely useless, except as a guide. The vaccine injection is bad to a person not in the best of health unless the correct injection is used. In this case streptococcus found in the vagina would not prove that she was not suffering from, say, pneumococcal infection of some other organ. In this case the streptococcus germ was found in the uterine swab. Streptococci are found in the mouth of otherwise healthy persons. They have also been found in the vagina of healthy women. In general septicaemia, where streptococci have been indicated, one would treat the patient generally to raise the powers of resistance, and where the presence of the germ has been proved one would inject streptococcus vaccine. That is a last resort. Some very drastic operations have been performed by some of the eminent authorities, but they have not been successful. The general treatment of general septicaemia is an expected treatment and nothing else. The main and practically the only factor in the cure of general septicaemia is the patient being able to fight down the poison. The cause of general septicaemia is due to the presence of streptococcus. The medical profession is in absolute disagreement as to the treatment of general septicaemia. One must strongly suspect septicaemia before submitting a patient to the operation of taking a swab. This is not a simple process. The trouble is that in the first few days of the puerperium one is very loth to actively interfere. One reason is the danger of introducing sepsis. It is much more dangerous to interfere with a patient just after the confinement than before. £urretting and intrauterine douches are now condemned by medical men for the same reason and others. Not having seen the patient at the beginning, I could not say now what I consider to be the primary cause of her death. It is impossible to say at what stage earlier than the 3rd of 4th September a becteriological examination would have given a negative test. The fact that the blood-test was negative on the 3rd or 4th would indicate that it would be still more negative on an earlier date. There would have been no trouble in finding streptococcus in the blood on the 3rd or 4th had the disease been of long standing. 1 would have treated the patient for some fever and given her some special treatment for the lung trouble up to the time of the discovery of the streptococcus. I have seen a good deal of the working of St. Helens. 1 have been there on other occasions. From what I have seen of the management of the home I have seen nothing to object to. As to cleanliness, the precautions taken are very good. My experience is that the nurses trained at St. Helens are very, very careful, and that there asepsis is very good indeed. I do not see any objection to the Matron of St. Helens Hospital suturing small wounds. Any wound should be sutured as soon as possible after it is made. I do not think the suturing itself had anything to do with the introduction of infection in Mrs. Chamberlain's case. If there had been any infection on the person who did put the sutures in I should say that would be the least likely time. I think contact with the Matron in any way is the least likely cause of Mrs. Chamberlain's sepsis. If it is proved that Mrs. Chamberlain had been mixed up with a septic wound that is a very likely cause of the microbes being on her body. I cannot think of any other cause for the infection. Gross-examined by Mr. Skelton.] 1 know of an institution in London called the Central Midwives Board. I have not lately seen a copy of their rules. I do not doubt that those put into my hand are the rules of the Board. [Exhibit No. 21.] They are dated 1903. I cannot answer whether I agree or not that sutures should be put in the perinaeum by other than a medical man where a medical man is reasonably available. There are places where qualified nurses put in sutures, but I have no experience of them. I w T ould not allow such in my private practice, because I am absolutely responsible for every private patient, I do not know who stitches perinaeums at Guy's. I suppose students would do it. Personally, I stitched many a one when I was a student of four years' standing. My studentship lasted five years. This was pretty close to the end of my studentship, but not close to the end of studentship in midwifery. I was qualified five years and a half after commencing my studentship at Guy's Hospital. The suturing done hr me was not supervised nor was it examined by my superiors shortly after it was done. As students we had charge of our own cases unless we thought it was one that needed what you call more skilled attention —that is, the skill of a registered medical practitioner. If nothing happened to the perinaeum stitched by the student it would never be examined by a registered practitioner. We were permitted to do this all through the studentship in midwifery. At the time we were in our fourth years. The trained nurses there were not what you would call midwives. I' never saw a trained nurse stitch a perinaeum at Guy's. I do not. remember hearing of such a thing. I cannot say that I know of my own knowledge of a trained nurse stitching a perinaeum. Ido not think a registered nurse who is not a midwife would be allowed

H. M. GOLDSTEIN.]

55

H.—3lb.

to suture in Auckland in private practice. Where the services of a medical man can be obtained they should not do so. In ordinary practice a midwife would not be allowed to suture. I made no notes of Mrs. Chamberlain's case which I kept. I jotted down notes which I took with me when going to see Dr. Inglis, but I did not keep them. I made no entries in the Hospital books at all, but I made entries in my visiting-books : these show' that 1 did Dr. lnglis's work on certain days. There is no reference to Mrs. Chamberlain's case at all. I remember well what I did on the various days that I attended Mrs. Chamberlain. On the first day Mrs. Chamberlain was seriously ill. She had a high temperature, but her general condition was good. She looked ill, but not so ill as I would expect a patient to look with that condition —that is, continued temperature, rapid pulse, and rapid respiration. The chest trouble was very indefinite. It looked as if some other condition were clearing up. I have a fairly clear recollection of what Dr. Inglis told me of the case. He told me that Mrs. Chamberlain had developed bronchial pneumonia just after her confinement, and that the case had turned into one of tubercular bronchial pneumonia. That is the important part of what he told me. He told me as to the condition of her chest—the signs. I do not remember him mentioning any suspicions to me. It must have been discussed, though. I think Mrs. Chamberlain's case was the only one that was specially discussed. I was told that the others were all normal, and this was the only one wanting looking after. Ido not remember if others were referred to. As far as I can remember, I have told you all that was referred to in the case. The suspicion of septicaemia was referred to. I do not remember how it was referred to, but I am certain it was mentioned. I do not know if notice was sent to the District Health Office about this case. Had I notified a case as one of septicaemia, and then had to call in another practitioner, I would tell him that I had so notified the case. I cannot answer the question as to whether or not it would not be the first and a very proper thing to do to tell the incoming practitioner that I had notified the Health Office that the case was one of septicaemia, Had I suspected the case so much as to send in a notice that I did suspect I would have thought it the first matter to mention to my colleague. I never was told that a notice was sent in to the Health Department, or that one was going to be sent in. Luncheon adjournment. To Mr. Skelton.] I was unaware that a form had either been filled in or sent to the Health Department at the time of my consultation with Dr. Lindsay. I examined Mrs. Chamberlain on the 29th. I made a general examination of her bod) 7 , and made a vaginal examination of the genital organs. I had taken over the case myself, and I had to examine the patient myself to be satisfied as to her condition. I found the signs of lung trouble to be diminished on the 31st. The lungs were more normal. The air-entry was better, and the row T had heard the first time was not there. It is quite possible that the lung trouble was due to a cold contracted in. the early part of August. I did not consider on the 31st that I could find sufficient lung trouble to account for or be the cause of the woman's illness. I could not say that her illness since her confinement was not due to lung trouble. On the 31st I thought there was something in addition to the lung trouble that was causing her illness. It is true that on the 31st August I could not find sufficient lung trouble to account for the illness to such a degree as the woman was in. It is not so that I came to the conclusion on the 31st that a mistake had been made in treating her only for lung trouble. I saw the chart. On the 31st I came to the conclusion that the chest trouble was not sufficient to account for the temperature and the pulse. The trouble had been an acute lung trouble from the start. I have confined my evidence since the luncheon adjournment to what T noticed since my examination. I am not in a position to say that the patient had an acute lung trouble. I was satisfied on the first day (29th) that the disease was due to lung trouble. I was satisfied that it would have accounted for her condition —temperature and pulse—as the vaginal condition was normal. There w r as no tenderness of the uterus nor swelling of any of the organs. That is what I swore this morning. On the 29th, when I first saw the patient, I w r as satisfied that her illness was due to the bronchial pneumonia. I satisfied myself partly from what Dr. Inglis told me and partly from what I observed myself. On the 31st I was satisfied that lung trouble did not account for the patient's condition. It would depend on the patient's condition when I could take a swab from the uterus to ascertain the patient's condition—a few days after the confinement, and that only after a strong suspicion of septicaemia. The usual signs of septicaemia are high temperature following a rigor, on about the third day after confinement, suppression of the discharge, tenderness of the uterus, rapid pulse, which would go with the temperature. I do not say that the chief signs are temperature and pulse; they are the main warnings of septicemia, I would not take a swab from the uterus at the first sign of septicaemia. Septicaemia is the bugbear of confinement cases. I would call it a worse name than that. It is a thing one should always be on guard against. If a patient a few days after her confinement developed a temperature and a pulse one of the first things that could come into my mind would be septicaemia, depending on the temperature and how 7 it came on. Even though I had other symptoms I would not disregard the warnings of septicaemia, If I considered the patient to be suffering from something else I would not take the swab, notwithstanding the temperature and pulse. If the symptoms of the chest trouble were not sufficiently severe to account for the temperature, then you would see about having a swab taken, provided the other trouble did not account for her condition. A pulse of 130 and a temperature of over 103 would immediately put me on my guard against septicaemia, because these are the first definite signs. After allowing a few days to go by after getting the first signs I would allow a few days to go by before taking the swab from the uterus. When I got the temperature and the pulse I was just as much on my guard against septicaemia as if " danger " were written up on the wall. If I found that the temperature were due to something else than a septic condition I would not take a swab. One likes to check one's diagnosis. To take a swab from the uterus might effectually check the diagnosis in this case. If the patient w r ere doing no good, I might come to the conclusion that

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56

[H. M. GOLDSTEIN.

that was due to my bad treatment or to my bad diagnosis. I expect that I would then immediately take steps to have a fresh diagnosis. To take a swab from the uterus would be part of the next step —a small part of the diagnosis; The fact that the temperature keeps up and the patient gets no better is not a sign of the failure of the treatment. It is absolutely impossible to diagnose some of the most violent forms of chest trouble, because there are no signs. The right time to take a swab from the uterus after the temperature reached 102 would be as soon as one could without endangering the patient. That could be taken, ssiy, four or five days after the confinement. It is safer to take the swab at that time than before. One wants to leave the patient absolutely alone for the first four or five days after her confinement. After the seventh day one would be fairly safe in taking the swab from the uterus. If I were suspicious I would reckon that taking it on the seventh day was quite safe, An attack of septicaemia is rare after the fourth day. If the pulse and the temperament kept up and my treatment was not successful, I would feel that I should check my diagnosis by taking a swab from the uterus. The test for pneumococcus is a blood-test and a sputum-test. There is sputum with bronchial pneumonia at any stage. It is not so that in cases of bronchial pneumonia the sputum necessarily shows pneumococcus. If the pneumonia were confined absolutely to the lung it would not show in the blood. If I had a case of suspected bronchial pneumonia I would apply the ordinary tests. I would use the stethoscope and take the sputum. If I were satisfied that the condition were due to some other disease I would not consider myself justified in taking the swab. I do not bother about testing the sputum in pneumonia cases if I am satisfied that it is a case of pneumonia. It is the duty of the practitioner to take every step in the case of a confinement to ascertain the cause of her feverish condition. If I am absolutely sure that I have got the cause I w r ould search no further. I think it was advisable in Mrs. Chamberlain's case to have an examination of the sputum. It is advisable to have this examination at the earliest possible stage. When I took over Mrs. Chamberlain's case I found she had a fair power of resistance. She was a fairly big woman. She was resisting the disease. It was as a result of my consultation with Dr. Lindsay that I made the suggestion for an examination of the blood. The result of this examination was not communicated to me. I had nothing to do with the case then. Sometimes the pulse becomes so fast as to be unaccountable, and yet the patient recovers. The pulse is not alarming when at 128. The continuous rise is alarming. A patient with septicaemia following confinement wall often say that she feels quite well. In a number of cases, including septicaemia, distension of the stomach is noticeable without pain or complaint from the patient. It is not usual to have a temperature of 104 keeping up week after week in cases of a cough. The infection could be general at first, though introduced from the vagina, the uterus, or the perinaeum. I must withdraw that; it w r ould have to be local first. The development of the fever would depend on the extent of the primary infection. It is rare to have normal lochia with streptococcus in the vagina or uterus. I have had more than two hundred maternity cases without a death. I do not think that is unusual. I remember a conversation with Chamberlain. It was on the evening after yve had seen Dr. Lindsay, on the evening of the day we had had the consultation. Chamberlain asked me what was the matter with his wife. I told him he would have to go to Dr. Inglis to get that information. He said he would go and see Dr. Inglis. I sent him to Dr. Inglis because it was Dr. Inglis's case, and he had seen Chamberlain before. Gross-examined by Mrs. Nicol.] Dr. Frost was called in on the 3rd September to make a bacteriological examination —a blood-test. To make a blood-test blood has to be extracted from a vein. One of the veins of the arm is usually taken. I did not see Dr. Frost take the blood. Usually very little blood is taken. I did not see it taken in this case. Adjourned to 28th.

Tuesday, 28th January, 1913. Ebenezer Joseph Thomas (called by Mrs. Nicol), on his oath, said. To the Commissioner.] I am house-manager at the Auckland Hospital, I produce a tem-perature-chart kept at the Auckland Hospital in connection with patient Mrs. Porch. [Exhibit No. 5.] This is the original. Mrs, Porch was admitted on the date shown on the chart— 18th September, 1912. She was discharged on the 17th November, 1912. There were two charts from St. Helens—tw r o separate charts—that is, two sheets. They w-ere sent down here by Dr. Maguire, Acting Medical Superintendent to Dr. Inglis. To the best of my belief Chart A is the one sent down from the Hospital. I know nothing of Chart B. What I produce is the temperature-chart, diet-sheet, and prescription-sheet, and a history of the case. [No cross-examination.] I also produce the charts relating to Mrs. Stevenson —temperature-chart, diet-sheet, prescrip-tion-sheet, and history of the case. [Exhibit No. 12.] Charlotta Ludwig, recalled by Mr. Mays,' saith. Re Mrs. Porch's Case. To the Commissioner.] I see Mrs. Porch's charts A and B. Both have been copied by me. I suppose the original chart has been torn up. I expect I tore it up wdien I copied it. It was an untidy chart, and I copied it. I made two copies—one for myself and the other for the General Hospital. I think that marked B is the one I kept for myself. It is a copy of the original. I had to send the chart to the General Hospital with the patient, and I was not going to send an untidy chart with her. Both copies were made from the original. As far as I can say, both copies were made from the original about the 18th September. The original was destroyed on or about the 18th September. I destroyed the original chart because it was untidy.

H.—3lb.

C. LUDWIG.

57

Some of the nurses do not keep the charts tidy. If the charts are untidy and the nurses have time I make them make fresh copies. If they have no time I do them myself. The two charts [produced] are not exactly the same. That that went to the Hospital has a little more explanation in it, I produce the chart relating to Mrs. Stevenson. [Exhibit No. 4.] It is the original. To Mr. Mays.] It is the practice in hospitals I have been in to destroy untidy charts after making copies. I have seen that done at the General Hospital at Nottingham, also at St. Helens at Christchurch. I went over the chart of Mrs. Porch that I sent to the Auckland Hospital with the original. To Mrs. Nicol.] I knew nothing about you asking a question in the House, which came out somewhere about the time the chart was destroyed. I knew 7 nothing about you at all. I destroyed the chart on my own authority. I did not know you had anything to do with Mrs. Chamberlain or that the case was coming up. I do not know who gave the information to Dr. Valintine that w-as conveyed by him in answer to a question you say you got Mr. Bradney to ask in the House. I know 7 nothing on the subject. I do not know to what you refer. I put a fuller explanatory note on the chart that went to the Hospital for their information there. We had the information in the case-book. The fuller notes were not taken from the temperature-chart. I cannot say that I took the two copies from the original at the same time. To Mr. Skelton.] Mrs. Chamberlain's chart is the original one. Copies have been made from this. Mr. Mays has two and Mr. Skelton one. They were made for use in this case. To the Commissioner.] When the trouble was made about Mrs. Chamberlain's case no special report was made by me to Dr. Valintine on the case. Dr. Valintine went over the Hospital some time in November. During the progress of the case I wrote from time to time to Miss Maclean about it. To Mrs. Nicol.] Dr. Valintine was through the Hospital in September. It was not an official visit. I remember Dr. Makgill being there with him. To the Commissioner.] I have not seen before this the report of Dr. Valintine now put into my hand. I do not know absolutely where Dr. Valintine got the information that enabled him to make this report. It may have been from my letters to Miss Maclean. Adjourned to 4th February proximo.

Tuesday, 4th February, 1913. [Medical certificate of cause of death put in at Mr. Skelton's request (Mrs. Chamberlain's case). (Exhibit No. 59.).] Herbert Myer Goldstein, recalled, saith. Cross-examined by Mrs. Nicol continued.] [Mrs. Nicol refers witness to page 35 of his evidence.] I have a fairly wide practice, wdiich extends over a fairly large area. I make no difference as to what patients I take first —whether those nearest or furthest. I have no general hour for starting out in the morning and none for coming home in the evening. I visited St. Helens twice a day during this time. Ido not know if I was rung up or not. I was at the home when I was told that Mrs. Porch definitely needed attention. It was about 4 p.m. I did not see her before the end of the first stage of labour. I do not remember at what case I had been before coming in to the home and attending to Mrs. Porch. I should say I was about an hour in the home before the birth of the child. The patient was on the delivery-bed. Four hours for the second stage of labour is not normal, but it is very usual. A labour of sixtyfive hours is not a normal labour. If a case is a simple straightforward one the child might be born in from eighteen to twenty-four hours. The time in Mrs. Porch's case is not unusual, though it is abnormal. One expects it in such a case as Mrs. Porch's. The time from the end of the second stage to the end of the third is not abnormal. The total of sixty-five hours is abnormal, but not unusual. When I first saw the patient the second stage was just starting. There is no sharp line between the various stages. When I first saw Mrs. Porch she was ready for surgical interference. I attended to her then. She had not been ready for surgical interference for any length of time—absolutely not. There was nothing in her condition when I first saw her that suggested to me that I should have been called in earlier. I had no reason to suspect that anything had been delayed or overlooked in her treatment. Sometimes one takes the risk of injuring the patient by hastening delivery. There was not equal danger to the mother and child by the protracted labour. I gave the patient chloroform, but not immediately on going into the room. I saw after I examined the patient that she was ready for immediate delivery. The perinaeum was ruptured. I put in two stitches. I saw the rupture. My attention was not called to it that I know of. I knew the patient was ruptured when I delivered her. When I am there I always put in the stitches. Mrs. Porch was put into ward No. 2. I did not see Mrs. Porch shiver violently. I visited Mrs. Porch the next day. Her temperature had risen. I visited her the next clay. I could not say whether it was with or without Dr. Inglis. It is usual to examine the uterus. I did so on this occasion. On the third day the temperature went up to fever height. I was suspicious of something being wrong from the first day. That was because the temperature was up. Temperatures always go up and down. I was suspicious of all sorts of things. The second time I saw the patient she was peculiar. I pressed the patient over the uterus to see if it was tender or enlarged. I have frequently allowed my patients to go to forty-eight, fifty, or sixty hours. Puerperal insanity alone could cause the temperature of 103. I concluded that the patient was becoming septic. I passed the case over to Dr. Inglis on the fourth day. I gave Mrs. Porch bromide medicine and vaginal douching. The douching was a precautionary measure. The temperature was still rising. It is generally done to give the douche when the temperature is rising. The case was one of puerperal insanity. The patient was removed to a room by herself on the third day. I saw her in No. 6. Dr. Inglis

31b.

H.—3lb.

58

[H. M. GOLDSTEIN.

ordered Dr. Frost to take the blood-test. Patient was removed because one suspected sepsis coming on from the temperature. I am certain I saw the patient in No. 6 ward, but I cannot say it was on the third day. The patient was given milk diet. Milk is practically the diet at the beginning of a septicaemia case. As a matter of fact, it was very difficult to get the patient to take anything. The question of food depends on the state of the patient. At a certain stage alcohol might be given. Rich foods might only make the patient more feverish. Re-examined by Mr. Mays.] The usual attitude of a medical officer in the early stages of the puerperium is what one would call expectancy. One would not interfere with the congenital organs without strong cause. Chest troubles could have accounted for Mrs. Chamberlain's temperature up to the 28th August. If Dr. Inglis founded his opinion on chest trouble I would not have expected him to take a swab before the 28th. There is a danger of infecting while looking for sepsis by means of an internal examination. I do not think it would have made any difference had the vaccine injection been made earlier. 1 can show 7 authority of recent date and high standing on the question of vaccine treatment of septicaemia. The streptococcus vaccine treatment is the one big failure of vaccine treatment. I quote from the number of January, 1912, of the " Magazine of Surgery, Gynaecology, and Obstetrics," a paper on puerperal infection discussed by the Gynaecological Society. Cook County Hospital therein mentioned is one of the famous hospitals of the world. I refer to page 107. I agree w 7 ith the opinion therein expressed that while there is great hope for the vaccine treatment of septicaemia it is not at present founded on any definite basis. This is the opinion of eminent Americans who, as a rule, are but too eager to take up new lines of treatment, and are not conservative. Some splendid work has been done by the vaccine' treatment. The same authority shows that when one suspects sepsis the best course to pursue is one of non-interference with the uterus. I endorse what Dr. Goldstein says on page 104 of the same magazine—that a conservative treatment is the best, and that he would not go into the uterus except in a case of hemorrhage. Puerperal cases have been very successfully treated in Auckland by a policy of doing nothing. Prior to treating Mrs. Porch surgically I had seen the Matron. I saw her the same morning. I made it clear to her at what stage of labour I was to be sent for. The patient had reached just about that stage When I arrived. I think the one reason Mrs. Porch is alive now is that I did not interfere earlier. Had I done so she might have been more torn about, in which her septic condition w 7 ould have been more serious. The only assistance one could give would be to end the confinement. I am of opinion that Mrs. Porch had a much more simple confinement as she was than if she had been delivered, say, the day before. Gross-examination by Mr. Skelton continued.] I attach no value to the taking early of a swab from the uterus. I quite agree that it is a proper tiling, after the temperature has reached 102, where there is reason to suspect septicaemia, to take a swab from the uterus on the fourth or fifth day after confinement, providing the swab could be taken with ease. The taking of a uterine swab to be of any use at all is a painful and delicate operation. It is a usual practice to take swabs from the uterus, and one which I have carried out myself. It is my experience that though the vaccine is given at certain times there is no proof that the patients are benefited thereby. The only case I had in private practice of the injection of vaccine after the taking of a uterine swab got better, but T do not say it was due to that. I would not go even so far as to say that the patient's getting better might possibly be due to the vaccine treatment. There are no statistics now to prove that septicaemia patients get better now in greater proportion under the vaccine treatment than they did before it. I cannot say that Mrs. Chamberlain's life might not have been saved by the injection of streptococcus vaccine before the seventh day. The injection of streptococcus vaccine is adopted at St. Helens. It is generally adopted in certain cases. Some of the great English authorities are in favour of the vaccine treatment. Vaccines were not in common use when I was at Guy's. It is a treatment of, say, the last three years. I would have administered the vaccine, because one hears and reads of cases that have been done good by it, The treatment is not harmful except in the acute stage. An overdose given at the beginning would have just the opposite effect to what it is given for. In the acute stage it might do more harm, than good. If the vaccine could be given right at the beginning it might do good, but it takes forty-eight hours to get the vaccine, and by that time the patient has either got into a chronic state or into an acute one and died. I know of a journal called " The Nursing Mirror and Midwdves Journal," published in London. I do not know that it is the official organ of the Central Midwives Board. Re-examined by Mr. Mays.] The position is that some doctors place no faith in the vaccine treatment, others, are doubtful, and others pin their faith to it, An opinion given after the death of the patient by a person not having seen the patient is not of real use. Cross-examination by Mrs. Nicol continued.] On the second day I saw her Mrs. Porch showed signs of insanity. The chart states that the onset of delirium was on the sixth day. That refers to a different stage of the mania. Re-examined by Mr. Mays.] The statement from the case-book is a fair statement of the patient's condition. Gross-examination by Mrs. Nicol continued.], The temperature rose from the first day. Martha Porch (called by Mrs. Nicol), on her oath, saith. I am a married woman, living at Auckland. I w 7 ent into St. Helens Hospital to be confined. I went in on the 28th August, and was confined on the 30th. I have made a statement referring to my treatment wffiile in the Hospital. That already produced is the one. It contains practically all T know about it, and it is quite true. I do not think there is anything I wish to add to it. The writing, "Mrs. Emily Porch," on, the statement was written by my mother-in-law. T saw her write it. I sat down and wrote out the statement without any assistance from any person. Gross-examined, by Mr. Mays.] Nobody spoke to me about the case before I w 7 rote out the statement. I was never asked to give evidence except by Mrs. Nicol, She did not ask me to

59

M. POBGH.

H.—3lb.

do anything. She asked me to come to Court, but I was not well enough, so I wrote it instead. I understood that if I came to Court I would be asked questions as to what I could remember of the case at St. Helens. I had never been at St. Helens before. I had chloroform, I saw the numbers on the doors of the rooms. The last room I was in was No. 6. I saw it on the door as I went in. I remember going in. Nothing in particular has been said to me about this case since it was decided to have an inquiry. A few words only were said. I suppose I have to be satisfied with my treatment at St. Helens. I know the labour was an instrumental one, because I heard some one say so afterwards. Gross-examined.] The nurses were extremely kind to me, especially Nurse Anderson. Tracy Russell Inglis, recalled, saith. Gross-examination by Mr. Skelton continued.] 1 cannot say when Dr. Valintine first visited St. Helens after Mrs. Chamberlain's death. The signature on the certificate as to cause of death is mine. I do not think I saw Dr. Valintine during the months of September or October. I got my training in gynaecological matters mostly from, personal teaching by two of the leading gynaecological practitioners in Melbourne. I have had personal experience since. I was qualified in 1899. I remember Dr. Brockway's diplomas coming through. I do not know the date. In refusing to consult with Dr. Brockway it was not because he was a doctor attending lodges. It is untrue that I stated to Chamberlain that I would nominate the medical man to consult and he would have to agree to my nomination. He asked me to suggest good men to consult with. I did not say I would consult with one of three mentioned and no others. I have never known of such a case of septicaemia where the patient is very bad and yet says she fees quite well. I have heard of Jellett's " Short Practice of Midwifery." I have not heard of Dr. W. J. Smiley as an authority on midwifery. I have not known the abdomen to distend painlessly in virulent cases of septicaemia. Painless distension of the abdomen is a symptom that occurs in some cases of septicaemia. I cannot say what the change in the symptoms was when I saw Mrs. Chamberlain again on the 3rd September. There was no definite change in her symptoms. I thought she was not improving. She w 7 as rather tending to get worse. As far as I remember there were no definite changes, further than the gradual getting worse. Between the 23rd August and the 3rd September the patient was certainly not improving. From my experience in this class of cases it is almost certain that asepsis will develop sooner or later. A symptom is only what the patient complains of. She made no further complaints. A sign is a different thing. From the 23rd to the 28th August there was not much change of signs or symptoms. She was not improving. There was a distinct change between the 28th, when I was taken ill, and the time I saw her again. Between the 23rd and the 28th the patient was practically stationary. I suspected that the patient was becoming infected about the 28th. About the 4th September she was getting a more septic, look. I have vivid recollection of her condition all through, as hers was an interesting case, but I find it very hard to put her condition into words. The definite symptoms of general infection were temperature, pulse, general appearance, and diarrhoea, which I think she had at that time. I could not describe the septic look. Her abdomen was a little more distended, and she had some pain there. Dr. Valintine did not, to my knowledge, go through the home while Mrs. Chamberlain was laid up there. In a severe case of septicaemia there are a high temperature (in some cases a subnormal one), rapid pulse (easily compressible, sometimes irregular), dry brown tongue, very often diarrhoea, usually pain over the abdomen, the abdomen may or may not be distended, respiration usually rapid, locally one may find signs of sepsis in the pelvis, the lochia may be offensive, may be suppressed, patient usually complains of headache, very often backache, may have pains all over, the patient has the general appearance of sepsis. This, while it can hardly be described, can be noticed at once by an experienced person. I concluded that the patient was suffering from chest trouble. The evidence that the patient was not suffering from septicaemia was the absence of the signs of sepsis. In my opinion, the signs and symptoms the patient disclosed that there was no septicaemia—l mean up to the end of August. The steps I took to form my opinion were a careful examination of the patient. That is all that could be done. I remember looking at the perinaeum one day. That was, 1 think, the 16th or 17th August, I examined it then. I separated the lips of the vagina and examined the perinaeum. I think there can be a normal lochia, though there be streptococcus in the vagina. If the streptococcus were in the uterus I think the lochia would be abnormal, but this is a debatable point. The principles of asepesis are explained to the pupil nurses at St. Helens, and in my lectures I. give them a demonstration, and they often see perinaeums stitched. I would permit the stitching of perinaeums in an institution by nurses, because in the institution they are under more supervision than in private practice. As to strict medical supervision, there is more in a case of a confinement in private practice than in the case of a woman confined at St. Helens. Had the sepsis been from an auto-infection in the lungs in Mrs, Chamberlain's case it w 7 ould be most probable that the blood-test would show the germs, but not necessarily so. If it came from germs found normally in the vagina the reason why sepsis did not show earlier was that the patient had her resistance lowered gradually by the bronchial pneumonia. It is more likely that there would be absorption from the vagina early after parturition when wounds and sinuses are open than later when they are closing or closed. Gross-examined by Mrs. Nicol.] I do not think the vaginal passage of a woman before confinement is aseptic. My opinion in this is borne out by a great number of authorities. I have known of a case where sutures have been put in in a private institution. I am not quite certain about it. I injected the vaccine in Mrs. Porch's case because Dr. Frost reported the presence of streptococcus in the swab. Mrs. Porch had three injections at intervals. That was with the idea of neutralizing the streptococcus that Dr. Frost had reported. I considered that the patient had puerperal insanity, complicated by septicaemia. The pelvic abscess I noted is a local septicaemia, I could not say what caused the insanity. It was puerperal insanity without a doubt. It comes sometimes without anything to account for it. Insanity does not come from such a protracted labour as Mrs. Porch had. I consider that her labour could not have been terminated

H.—3lb.

60

T. E. INGLIS.

sooner than it was. I do not think Mrs. Porch's insanity had anything to do with the protracted labour. I found out that the patient had a pelvic abscess the day before the patient went to the General Hospital—either that day or the day she went there. I examined her several times. I gave her the vaccine because of the report of the bacteriologist. Mrs. Porch w 7 as kept as isolated as we could. Others had to pass the door of the room where she was isolated. The door was often open. That was no detriment. In my opinion, the isolation was quite sufficient. Re-examined by Mr. Mays.] In the early stages of puerperiuin the ordinary practice for a practitioner it to leave the genital organs alone as much as possible. Where the presence of streptococcus is reported the vaccine treatment as a recognized treatment, but as to this there are differences of opinion. Some have great faith in it, others have not, and some look on it indifferently. I look on it as a last hope for the patient. I have no faith in the swab test. • I do not altogether believe in the streptococci vaccine. I would not say that it does not do harm in some cases. I thought in this case that the chances from giving it w 7 ere better than from not giving it. It is not a set treatment for septicaemia. I think that the vaccine treatment is one that is on its trial, and needs to be used with caution. I w 7 ould give very small doses, and watch the results very carefully. 1 would not give it unless I did not think there was much hope for the patient. If the germ were found in the blood-culture, then I would adopt the treatment. A great many authorities do not use it if the blood is sterile. If the streptococci were found in the blood I would adopt the vaccine treatment, but I would not put it down as an absolute cure; but not so if the streptococci were found in the swab. I think it is possible that in time some treatment of puerperal sepsis may be evolved on the liens of vaccine treatment with more or less certainty of cure. lam certain I was at St. Helens on the 12th August because I gave a lecture on that day. I stamped my book on that day. I wrote out the notice of infection on the 28th August —the day I was taken ill. Mrs. Porch was the next patient in respect of whom I sent a notice. I wrote hers on, I think, the 6th September. I had no occasion to refer to the block of notice-book from the 28th August to the 6th September. Thinking the circumstances over, I may not have posted the notice referring to Mrs. Chamberlain till I got out the block again to send the notice referring to Mrs. Porch. I was ill at the time, and do not remember posting the notice at all. I do not remember finding the notice unposted and then posting it. I do not remember telling Dr. Goldstein that I had sent a notice. I went to Australia on the 23rd September. I visited St. Helens on the day I left. I returned on either the 20th or the 21st October. I was away on account of my health. Vaginal examinations at an early stage of the puerperiuin are regarded as dangerous; they are not to be lightly undertaken. If the streptococci had been in the uterus in an active form much earlier than they were found by Dr. Frost the uterus would not have involuted as it did; it would have been larger than it was; there would probably have been tenderness; there may or may not have been a distinctive discharge; and the general condition of the patient would have been much w 7 orse. There were no such symptoms forty-eight hours before Dr. Frost took the swab. In my opinion, there were no definite local signs of sepsis till after Dr. Frost took the swab. Had Mrs. Chamberlain's sepsis been caused by absorption from the vagina at or just after the confinement I think she would have died much earlier than she did. Had the sepsis been caused by absorption from the vagina there would have been much earlier and more definite signs of septicaemia. As to Mrs. Porch's case : There is a theory that puerperal insanity may be connected with septicaemia. I have w 7 atched the matter to a certain extent in cases I have had under my care, but I do not think I have ever had a definite result. I have had cases of puerperal insanity where there was no sepsis at all, except as to a temperature which accompanies puerperal insanity. Mrs. Porch was removed to the General Hospital because she had a pelvic abscess, and I thought she needed an operation, and there were not sufficient facilities at St. Helens to carry this out. I operated on her and attended her during the latter part of her illness at the General Hospital. It was by a coincidence and not an arrangement that I operated on Mrs. Porch. I did it at Dr. Gillon's request. I saw Mrs. Porch here to-day. I was surprised to see her looking so well. I think she had a yvonderful recovery. I have read Mrs. Porch's statement put in in this inquiry. I remember her mental state. I think it absolutely impossible that she is capable of remembering the facts she has set down in her statement. She was insane most of the time she was in the General Hospital, and I think a woman who has gone through a period like that is incapable of remembering the things she has set down there. The direction in the Midwives Regulations against suturing are applicable to cases wdiere there is no medical man in attendance. Very often in private cases the medical man does part of the nurse's duties. At the time Mrs. Chamberlain entered St. Helens I was attending no septic cases in my private practice. It was at least a year back since I had a septic case in my private practice. I would not go direct from a case of puerperal sepsis to the maternity hospital. I w 7 ould not go to the Hospital from a septic case without going home first and having a bath and changing my clothes. I would then use gloves when I went to the maternity hospital. In these matters a surgeon has the advantage of a physician. Cross-examined by Mrs. Nicol.] I injected the streptococcic vaccine into Mrs. Porch as the best treatment for her. I think puerperal fever is more contagious than infectious. Had Mrs. Porch not had the pelvic abscess she would have been sent to the Mental Hospital. Under the existing circumstances, I would have been right in sending her to the Mental Hospital. She had puerperal insanity. To the Commissioner.] I cannot say how I fixed twenty days in the death certificate as the time from the attack to the death. It was just a haphazard guess. I would not say that the certificate is correct in that respect. I do not, in giving certificates of death in private cases, give the number of the house. I give nothing further than the name of the street. If I know the number of the house I put it in, but I never give the name of the house. All cases of death at St. Helens are reported to the Department.

Adjourned to sth.

61

H.—3lb

Wednesday, sth February, 1913. [Mr. Skelton explains that Mrs. Nicol will not be here until the afternoon, and that she has no objection to the evidence regarding Mrs. Chamberlain's case being proceeded with during her absence.] Peter Alexander Lindsay (called by Mr. Mays), on his oath, saith. 1 am a duly-qualified and registered medical practitioner, practising in Auckland. On the Ist September last, at the request of Dr. Goldstein, I saw 7 Mrs. Chamberlain at St. Helens Hospital. She was in the isolation ward. I had heard that she had been ill for a week or two. [Mrs. Nicol here appears, and asks to be excused from attending for the rest of the morning. Dr. Endletsberger called while she is present.] Theodore Endletsberger (called by Mr. Mays), on his oath, saith. 1 am a duly-qualified and registered medical practitioner, practising in Auckland. I am M.D. Vienna and Berlin and F.R.C.S. and Ph. Vienna, I have been practising here for about a year. I got a telephone message a little after 9 yesterday morning, and I was asked by the lady who spoke, who gave the name of Mrs. Nicol, if I could be of any help during this inquiry. 1 asked in which way, and was told as an expert. I said 1 did not know anything about the case. I had not read the papers. She asked if she could see me. I said she could do so at 2 o'clock. She also asked if she could bring somebody with her. I said she could do so, and that closed the conversation. I naturally inquired subsequently all about the case. I asked some of my friends about the case. I asked Dr. Coldicutt and Dr. Casement Aickin, and what I heard from them prompted me to call on Dr. Inglis. 1 went to his office in Eccles's shop. I asked him if he would speak to me, and so he did. 1 asked him about the case which was on, and lie gave me some principal views on it. He spoke of one case of sixty-five hours' labour. I told Dr. Inglis that Mrs. Nicol had rung me up, and that I had spoken about the cases with the doctors I have mentioned. Dr. Inglis spoke of a case about a woman who died of septicaemia, and where it w 7 as suggested that she was not correctly treated. The question about the sixty-five hours' labour was very easily settled. It took us about a minute to agree on it. Dr. Inglis iasked me how such a case ought to be treated. I gave him my opinion and he g-ave me his, and our two opinions agreed. We discussed the septicaemia case, and I came to the conclusion that I would rather not be put into the position of being muddled up with the case at all, because f think these are such scietific .matters that one man or a body of medical men could not decide on it, the matters being still under discussion in the leading universities in the Old Country. So I w 7 as determined not to give any opinion to any layman out of Court. At 2 o'clock this lady called on me —Mrs. Nicol. She w 7 anted to shoyv me some papers and explain the position to me. I said, " Before we go any further, I want you to understand that since this morning I tried to get some information about the matter in hand. I have seen and spoken to Dr. Inglis. I fully agree w 7 ith his views. I will not give any opinion on the case to you here. I will not discuss the matter; but, of course, you are at liberty to subpoena me." At this Mrs. Nicol left. Last night Dr. Inglis rang me up, and asked me to be here at 10 o'clock. We did not discuss anything. Cross-examined by Mrs. Nicol.] I belong to the British Medical Association. I believe Dr. Coldicutt belongs to it too, but cannot tell. Dr. Aickin belongs to the British Medical Association at Home, and he told me that he had applied to belong here. You asked me when you rang me up if you could bring some one with you. 1 did not catch the name. You said nothing about Dr. Marchesini sending you to me. To the Commissioner.] I did not discuss the case with Mrs. Nicol because I think the scientific matters of such importance should not be discussed yvith laymen. Gross-examined by Mr. Mays.] Dr. Inglis did not in the least do or say anything to dissuade me from coming here. To the Commissioner .] I inquired who Mrs. Nicol w 7 as, and then went to see Dr. Inglis. That was because I did not w 7 ant to do anything in which a medical man was concerned wdthout letting him know about it. Peter Alexander Lindsay, examination continued. Having learnt that Mrs. Chamberlain had been ill for a week, or two I expected to see some one looking much more ill than she did. I thought she looked very well. I examined her thoroughly. I found no definite local symptoms of any kind. With Dr. Goldstein I examined the patient, particularly with reference to the state of her chest. I could not find any physical signs which w 7 ould lead me to suppose there was anything wrong in her chest. I had been informed that her chest had been a source of anxiety before, and in the absence of definite local conditions in her chest I expressed the opinion' that it was prudent to regard the case as one of septicaemia, apparently generalized, especially as it was in a maternity hospital. This was in view of the fact that the chest symptoms had cleared up. There was no actual proof then, and there is none now, that the patient had generalized septicaemia, I prescribed no course of treatment To the Commissioner .] I saw the patient but once. I signed the visitors' book to record my visit. I looked for chest trouble, but could not find any. To Mr. Mays.] I see the chart. It does not help me to definitely form an opinion as to what the patient was suffering from before I saw her. The chart is quite consistent with bronchial pneumonia. The chart is quite consistent with bronchial pneumonia as explained to me in this case.

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To the Had I not heard anything from Dr. Goldstein or Dr. Inglis I w 7 ould not express any opinion on the subject of bronchial pneumonia, because any opinion I might express w 7 ould be worthless. To Mr. Mays.] I know from the chart that the vaccine treatment was tried on three occasions. To the Commissioner.] I told Drs. Goldstein and Inglis that the case was one of septicaemia. I. suggested to Dr. Inglis to get Dr. Valintine to come up and investigate the cause of the septicaemia in the home. He told me he had already arranged for Dr. Valintine and Dr. Makgill to come up. Dr. Inglis was to resume his duties at St. Helens on the following day, and he, I think, did so. To Mr. Mays.] Septicaemia has been the cause of tremendous mortality in maternity cases, and one suspects it in every case where there is suspicion of anything wrong; but despite all efforts it gets in, and one cannot tell the reason why or where it comes from. In every modern home with every modern contrivance, and conducted on most up-to-date lines, there will always be built a septic ward or room to deal with such cases, so liable are they to occur. My views on the treatment of septicaemia are perfectly futile in settling a case of this kind. The matter is being widely discussed by the profession world-wide, and there is no agreement as to its • treatment. I see the two prescriptions put into my hand. [Exhibit .] As to the one of Dr. Inglis, I say that that is a suitable prescription for tfie condition for which he was treating the patient. I say the same as to the prescription of Dr. Goldstein. My own experience of vaccine treatment is that it is very unreliable, and does not give the results one expects. In cases where benefit follows the use of them there is no certainty that the benefit was due to the vaccine. In the very cases in which one depends on it as being the only thing that will save the patient's life it will fail one. I have paid several visits to St. Helens. I consider it a most admirably conducted institution. I have no fault to find or criticism to make on the matter of sepsis and cleanliness from a medical point of view. On many occasions I have employed nurses who have been trained at St. Helens, and I can only speak in the highest terms of how 7 they do their work under the most trying circumstances. I would be perfectly satisfied to do all my midwifery with St. Helens nurses in charge of the cases. If the Matron knows how to put a stitch in there is not the slightest reason why the Medical Officer should be bothered while she is there. I am not sure that Mrs. Chamberlain died of septicaemia, I have not formed any opinion on the subject. It is impossible to say how the germs get in. There is in every woman a very big wound where the placenta peels off —a much bigger wound than that in the perinaeum. As a safeguard against sepsis the sooner sutures are put in the better. Cross-examined by Mr. Skelton.] I do not think I have discussed Mrs. Chamberlain's case with Dr. Inglis since the morning I spoke to him. about it over the telephone. I have discussed it with Dr. Goldstein many times. My examination on the Ist September consisted in taking the temperature, pulse, and examining the chest and abdomen, and inquiring from Dr. Goldstein and the nurse as to any vaginal discharge and as to the state of the perinaeum. I did not examine the perina-um. I was given to understand that it had completely healed, and that there had been no local trouble anywhere. I would not say that as a rule septic infection rarely occurs after the fourth or fifth day. The leading signs of septicaemia -are rigour, wdiich may not always be present, rise in temperature, quickened pulse, headache. The temperature and pulse are the leading features. With these I am immediately on my guard against septicaemia. If I suspected a patient was suffering from bronchial pneumonia I would want to check my suspicion. I w 7 ould do this by examining the chest, not necessarily the sputum. The examination of the sputum w 7 ould afford no help, because there is no such thing as the germ of bronchial pneumonia. Very likely one would find pneumococcus in the sputum. One would not alter one's opinion if one did not find it. Had I a case of bronchial pneumonia I w 7 ould examine the patient's chest with the stethoscope — nothing else. It is the rarest thing in the world to take the. sputum and examine it in a case of suspected bronchial pneumonia. I disagree with Dr. Goldstein that taking. the sputum for examination is one of the usual tests for bronchial pneumonia. The examination of the sputum affords no test of any settled value in confirming the diagnosis of bronchial pneumonia. I have been twentyfive years continuously in practice in Auckland. I came to the conclusion in a maternity hospital like that that it was prudent to look on the case as one of septicaemia. If the patient's temperature keeps up for three days, and one could not find any other cause for it, one would suspect septicaemia. If no other cause existed and the temperature kept up for, say, a week, I would then suspect septicaemia. The chart is quite consistent with two things—bronchial pneumonia and septicamia, and both together. The embarrassment of the respiration and cough are signs of bronchial pneumonia that would be noticeable to a layman. With chronic bronchitis there might be nothing but a cough and expectoration—no temperature. Dr. Inglis's prescription, I conclude, w 7 as given for some tubercular condition. Ido not know 7 Edgar's " Practice of Obstetrics." I have never had occasion to use the vaccine injection in midwifery practice, though I have used it in ordinary surgery. In cases of septicemia a great many practitioners use the uterine douche, w 7 hile a great many disapprove of it. I have used it in a number of cases, and if used with care there is not much danger to be anticipated from its use. I have taught a nurse who was going into the country to put in a suture. In my ordinary practice I would not allow a trained nurse to put the sutures in. A perineal wound is one dangerspot for infection To Mr. Mays.] In the case of a woman having been confined, and where you strongly suspect septicaemia, what steps would you take? —I do not know. T have had very little experience. It is a question that no medical man could undertake to answer. Re-examined by Mr. Mays.] I have had cases of general sepsis. I have treated them locally by washing out the uterus. I have had another class where there was no special treatment, and the patient recovered. The main factors in general septicaemia are the virulence of the

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germ and the resistance of the patient. Some germs will kill in a very short time, others will cause the patient to be ill for a very long time, and yet they recover. Mrs. Chamberlain made no complaints whatever to me. There may be no sputum in the early stages of bronchial pneumonia. I would not allow a matron or nurse to suture a rupture which penetrated the muscular tissue. So long as a rupture does not penetrate the muscular tissue I see no harm in the Matron suturing it. The sooner a possible source of infection such as a ruptured perinaeum is closed the better. To the Commissioner.] I know the Hospital, its grounds and position. I say that in my opinion the building is not a satisfactory one for a maternity home. I do not think there is any reason to be dissatisfied w 7 ith the results obtained at St. Helens. In a building of the kind it should be constantly disinfected. The site is convenient and easily getatable. That is the only advantage I see about the site. A site in the neighbourhood, but a little farther away from the trams, would be better. I do not think it is right that the maternity hospital should be an adjunct of the General Hospital. I think they are better apart. It would not be a good thing to have a hospital of this kind as an adjunct to the General Hospital. I think the existing site is one that should be abandoned if a more suitable site can be readily obtained. I agree that an institution of this kind, should be as near perfection as it is possible to get it. I say it would be a preposterous thing to have a medical man to do nothing else but the work to be done at St. Helens —that is, I think there is no necessity for a resident Medical Officer. I do not think it necessary that there should be more than one Medical Officer. The salaiw should make no difference to the attention paid to the institution. I see no objection to a practising surgeon or physician being the Medical Officer of the institution in conjunction with his own work. I think it well that the fullest record should be kept of each case. The object of" a casebook is to have the information in a case like this. A note need not be made from day to day, so long as the entries cover the period. The case-book should always be up to date, in case it is asked for. To Mr. Mays?] One could not, get a resident of good obstetrical experience under a large salary- The results of St. Helens do not justify any alteration in the matter of appointing a Resident Medical Officer. When I visit St. Helens I always get my information from the Matron. To the Commissioner.] The institution could not be worked if the inmates were to be permitted to nominate the practitioner who was to attend to them. To Mr. Mays.] I think it a reasonable thing for the patient's own medical man to ask to be allowed to see the patient, and I do not think such a request would be refused. Consistent with the proper management of the home, facilities might be provided to that end. To the Commissioner.] The matter of admitting an outside practitioner is one of arrangement. Charlotta Ludwig, recalled, saith. To Mr. Mays.] Mrs. Chamberlain was admitted to the home on the 10th August, 1912, in the forenoon. I cannot say the hour. I saw her an hour or two after. I was out when she arrived. I w 7 as present in the labour-room during the delivery. Nurses Jones and Edgecumbe were with me. When I first saw Mrs. Chamberlain I thought her run dowm. She did not look well. The labour-bed on which she was placed was the same bed as you saw in the ward some time ago. It was arranged as you saw it. I would describe the confinement as quite normal. The delivery-book covering the date concerned here has been destroyed. The casebook is in my handwriting. I cannot say on what date I entered it up. It w 7 as after Mrs. Chamberlain died. The books from w 7 hich the case-book was entered up are not now 7 in. existence. There was a rupture of the perinaeum. I would describe it as a superficial tear. To the Commissioner.] I superintended. Nurse Jones actually delivered the woman. Nurse Edgecumbe assisted. Nurse Jones is a pupil nurse, and so is Nurse Edgecumbe. Nurse Edgecumbe had been in the home about seven months; Nurse Jones not quite so long. I was in charge of the confinement, The pupil nurses were allowed to handle the child during the confinement, with my assistance. To Mr. Mays.] The rupture did not penetrate the deep muscles. 1 sutured the rupture. I put in tw 7 o stitches. I have done between fifty and sixty ruptures in Christchurch and Auckland. My own common-sense guides me in determining whether to suture or not—that is, whether to do it myself or call in the Medical Officer. 1 was submatron in Christchurch for not quite eighteen months. The labour-bed is made rigid by means of boards placed beneath the mattress. That is to prevent sagging. It is difficult to manage a patient in a bed that sags. In the case of hemorrhage it would be dangerous to have a sagging bed. Ido not remember that Mrs. Chamberlain was wet up to the armpits during labour. She recovered like any normal patient. I noticed nothing then or for a little while afterwards. I cannot remember whether or not Mrs. Chamberlain shivered. It is not unusual for patients to shiver immediately after the child is born. If they make any complaint they are covered up. Mrs. Chamberlain had three thicknesses of blanket covered over with the sheet. We have another blanket ready for them if they complain of the cold. I cannot remember that Mrs. Chamberlain complained of cold. If I feel that the room is cold I shut the window and give the patient hot bottles. A thermometer was there, but it got broken and was not replaced. After labour w 7 as over I gave the patient an injection of ergotine. This is usually injected in the hip. This is routine treatment. No other injections were made in Mrs. Chamberlain's arm up to the time she was removed to the isolation ward. She complained of nothing the first day. After confinement she was removed to No. 9. There was nothing unusual about the patient on the 11th, except the temperature. She yvas alone in No. 9 for the first day or two. I cannot say as to the rest of the time. Dr. Inglis first saw her on the 12th August—the second day. It was in the afternoon. I had rung him up that morning. I told him that the patient had been confined the morning before. The labour was normal, and the perinaeum had been ruptured, and I had sutured it,

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and that the temperature and pulse had slowly risen since. I was present when Dr. Inglis saw the patient. She made no complaint at all. There was nothing to show that she was bad at all. Except for the temperature and pulse she showed no symptoms of anything else. I think Dr. Inglis saw her the next day, but cannot be certain. I think it was the next day, because lie told me to put her in a separate room. He carefully examined her in my presence. She showed no further signs except the slight cough she had. She had this when she came, but it was slight. She was transferred to No. 3. That was because Dr. Inglis thought it would be wiser to put her in a single room on account of her temperature. As far as I can remember, Dr. Inglis saw her every day after that till he became ill. During the first three weeks there was very little change in the patient. She needed very little attention. Mrs. Chamberlain complained once, on, I think, the third day, that the stitches were sore. I looked at them and got Dr. Inglis to do so too. There was nothing unusual about them. Mrs. Chamberlain said nothing further than that the)' were sore. As a rule I take the stitches out about the eighth or ninth day. The condition of the perinseum was quite normal—quite healed when I took the stitches out. I recollect Dr. Goldstein coming in, and Dr. Lindsay too. Under Dr. Inglis's directions the patient was removed to the isolation ward. At that time Dr. Inglis told me she was suffering from chest trouble. She was removed because of the continued high temperature, and Dr. Inglis thought it wisest to isolate her. One of our own nurses attended to her there for a week or more —Nurse Way. Nurse Way did nothing else during- that time but attend to her. She did not come into the main building at all. About the 2nd September Nurse Adams—a general trained nurse —was put in charge of the patient. She was got from the Nurses' Residential Club. She was got because the patient was needing more attention and Nurse Way was not a trained nurse. Mrs. Chamberlain fed her baby for a time. I cannot remember how long. When the milk went off we had to feed it alternately, and then take it off altogether. Mrs. Chamberlain complained of sore nipples. This is not unusual with first babies. The usual remedy was applied. I used to go three or four times a day into the isolation ward and inquire how the patient was. The nurse was with her night and day—the same nurse. Nurse Way went away for a holiday for four or five days after leaving the isolation ward. I do not think Mrs. Chamberlain ever told me anything about what she had been doing before she came into the home. I suppose I saw Mr. Chamberlain on the first day Mrs. Chamberlain came in. I asked him —I think it was the first time I saw him —as to his wife's condition—if she had been well—and said she was not looking well. He told me that he did not think that his wife had been very well—that she had been run down. He said that she had been nursing her mother. He said he had noticed her quick breathing at night, and that she had been tired out. He did not tell me what his wife was nursing her mother for. He asked me at different times what was the matter with his wife, and how she was getting on. I told him that the doctor said she was suffering from chest troubles. I never told him anything different from that. When he was not satisfied I told him that I could only tell him to go to Dr. Inglis. On, I think, the day after the removal to the isolation ward Chamberlain said he was not satisfied, that his wife wanted to go home, and he asked if he could take her. I told him that he would have to sign a paper to say that he was taking his wife out at his own risk and against the advice of the doctor and the Matron. He said he would have to get advice about it. I understood him to mean medical advice. Mrs. Chamberlain never complained to me that she had caught cold on the labour-bed. She never complained that she got wet through on the labour-bed. It is quite likely that I said to one of the nurses in attendance, " You should not have done that." I do not remember it. I recollect nothing done by either of the nurses of any gravity or moment which might have affected Mrs. Chamberlain. Mrs. Chamberlain never complained of the nurses handling her roughly. I never heard till here that she had pressed her breast and that blood and matter had issued from it. She never complained to me about the room she was in being a thoroughfare. She never complained about her treatment in any way. The only thing was the soreness of the stitches. Mrs. Chamberlain was put in No. 3 so that she could be wheeled out on to the balcony whenever it was fine. I have seen a fair number of other cases of septicaemia. I never saw any symptoms of septicaemia in Mrs. Chamberlain. Whenever I asked her she said she felt all right, and could sit up in bed. So far as I know, everything was done for Mrs. Chamberlain that was possible. Up to the last week no injections were made in Mrs. Chamberlain's arms. I often examined the abdomen by pressure from the outside. Now and again the patient had distension, due to flatulence. Dr. Inglis said it was so. The involution of the uterus was quite normal. The lochia was absolutely normal. The patient had an unpleasant odour about her whole body— an unhealthy odour. Gross-examined by Mr. Skelton.] I hold a certificate issued by the Central Midwives Board. I did not in England hold the position of matron or submatron. My first position was submatron at Christchurch, in October, 1908. I held that appointment for just on eighteen months. Dr. Inglis did not mention to me till the latter end of August his suspicions that the patient was suffering from septicaemia. I think it was the day before he was taken ill that he told me he was reporting it because he really thought it must be septicaemia. He thought she was showing some signs of septic trouble. Mrs. Handley was in the isolation ward last before Mrs. Chamberlain. She was in three or four weeks before (Case-book No. 1321). She went home on the morning of the 23rd August. The vaginal douches were ordered by Dr. Inglis for subinvolution probably. The ward was disinfected by Nurse Anderson before Mrs. Chamberlain was put in. I told her what to do, and I went in and saw that it was done. I was not there all the time it was being done. 1 gave the instructions to the nurse, and I relied upon her carrying them out. You can always tell if the fumigation has been carried out properly. You go and sit in the room after it is finished. I told her to stuff up the ceiling-ventilator, to turpentine the bedstead, disinfect the floor, hang up the blankets, all the boilable things to be soaked in disinfectant before sending to the wash. Nurse Anderson was a pupil nurse then. When

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Mrs. Chamberlain left the place was washed down with Jeyes fluid. Mrs. Handley's was not a septic case. Nurse Jones had been there about five months when Mrs. Chamberlain's confinement took place. She had had no previous training. Nurse Edgecumbe had been a pupil nurse for nine or ten months. She came in December. Nurse Jones managed the delivery of the child. I was in the room at the time of delivery. Before the actual delivery I was in and out of the room. I guided the nurse in the actual delivery. I cannot tell you exactly what Nurse Jones did—l have had so many cases. I cannot tell you what steps Nurse Jones took to guard against a rupture of the perinseum. We have had forty or fifty cases since then, and I cannot remember any one in particular. 1 always assist the nurse, especially with a first baby. I guide the hand. Mrs. Chamberlain might easily think that 1 gave no assistance. I have tried to think, and have asked the nurse with a view of ascertaining, what could have been meant by my saying " You should not have done that " —that is, if I did say it. There were three cases of first pregnancy between the 12th August and the Ist September in which there were ruptures of the perinseum. It is not at all correct that ever} 7 woman who comes in, especially with the first baby, looks run down. It is not usual to hare a woman look run down just before her confinement unless there is some cause for it. The patient comes in in the ordinary confinement looking in her ordinary health. Except for the outward sign of the pregnancy, one would think there was nothing wrong with her. If there is no absolute cause, i(is a most unusual thing for a woman to enter upon her confinement looking ill. I have read through a good many times the " Rules for the Guidance of Midwives " issued by the Department. 1 refer to the " Rules for the Guidance of Midwives," now put into my hand. We keep a supply of these at the home. Our supply comes from the Department in Wellington. I see that every pupil nurse is supplied with one. A case is abnormal when there is hemorrhage— when there is an abnormal presentation. Where there is a rupture of the perinseum I would not call that abnormal. It often happens. I would not say a labour was abnormal because there is a rupture of the perineeum or other serious injury of the soft parts. It is a normal labour with a complication. I consider that 1 am entitled to suture ruptures of the perinseum, but only with the permission of the Medical Officer. When I came here first I asked Dr. Inglis if I would be allowed to do it. I asked it because I had been allowed to do the suturing in Christchurch. Dr. Inglis told me that lie allowed the Matron to suture in the case of small tears. I have been in the habit here of doing the suturing in cases of small tears. I do all superficial ruptures, but none that go into the deep muscle. I know that there is a publication called the " Nursing Mirror and Midwives Journal." I do not know that it is the official organ of the Central Midwives Board. I did not measure the tear in Mrs. Chamberlain's case. I can only guess at its length and depth. I destroyed the delivery-book which contained Mrs. Chamberlain's case. I cannot say when. It is not a book we are obliged to keep. We keep it for our own benefit. I cannot say the month in which it was destroyed. It was destroyed when the nurses were finished with it. It is for them. They take notes from it. In the book were noted the times of the different stages. If the nurse is inexperienced and does not understand she conies to me and asks what is to be done. I really could not tell if the book was destroyed before November last. Sometimes the cases run two or three months before the caseiTnok is entered up. 1 cannot say when I entered up Mrs. Chamberlain's case. When I have a spare day I write them up. It may have been quite a month after Mrs. Chamberlain's death that I wrote up her case in the case-book. It might have been even more than that. The casebook is not entered up from the delivery-book, but from the nurse's notes of the history of the case. The nurses' notes from which Mrs. Chamberlain's case was written up have been destroyed. I destroyed them myself. There is not a single original note (except the chart) in existence relating to Mrs. Chamberlain's case that I know of. I cannot say that the patient was wet to the armpits. I swear that Mrs. Chamberlain never complained to me that she was wet through. I was on good terms with Mrs. Chamberlain all the time she was there. I think Dr. Inglis only saw the perinEeum the onee —that was, I think, the third day, the 13th. That was not the first day he had called. He had called on the second day of the confinement. Mrs. Chamberlain did not complain of a throbbing pain. I never heard the word " throbbing " used. Ido not remember the exact day I took out the stitches. I would not swear that I took them out on the ninth day. As a rule, the stitches are taken out on the eighth day. When I swore that I put in two stitches I was going by the book. I have only once put in three stitches. That was a long time ago. [Delivery-book put in (Exhibit No. 31).] A first-degree tear is any slight laceration of the fourchette. It may not even need a stitch. As far as I know, I did not put in more than two stitches. I will say that T did not put in more than two stitches. I may have spoken to Mrs. Chamberlain about the suturing after it was done. Ido not remember It is not a , usual thing to tell the patient how many stitches have been put in. I do not think it possible that I put in more than two stitches. Had they all been superficial I would have put in three stitches. I always enter in the book the exact number of stitches put in. There was do rigor in Mrs. Chamberlain's case. I have a perfect recollection of that. I always condense the nurses' notes for the purpose of entry in the case-book. The information in the case-book as to Mrs. Chamberlain nursing her mother for several weeks I gathered from several persons. The mention as to the patient having influenza I gathered from what the patient told me in repry to my question, "Have you had influenza?" Shs then said, "1 might have had it." T had been questioning her as to her health and as to the reason for her not looking well. As to the bowels, no entry means no movement. The temperatures are taken by the pupil nurses. I have never found them untrustworthy. The distension of the abdomen may have been and probably was noticeable on the 16th. It always wont down after an enema was given. I think her abdomen was distended four or five times, and under the doctor's instructions she was given an enema. I have heard of other complaints as to the labour-bed. The patients have not made the complaints themselves while they have been inmates. I have not heard complaints afterwards. I heard that Mrs, Chamberlain complained that all that- was under her 9-B, 315,,

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was a piece of blanket and a piece of waterproof sheeting. She had under her a mattress 4 in. or 5 in. thick. The labour-bed does feel hard, especially to a patient who has been accustomed to a soft mattress. New 7 patients coming ask if they are put on a marble slab. I may have told Mrs. Chamberlain that it w 7 as usual to take out the stitches about the ninth day. I heard nothing about Mrs. Chamberlain pressing her breast and blood and matter issuing from it. Mrs. Chamberlain said nothing to me about it. I may have pressed Mrs. Chamberlain's stomach on the fifth day. I would not deny the conversation as to her having wind on her stomach on the fifth day. I fix the first visit of Dr. Inglis from the fact that he came to lecture that day—that is, the 12th August, The lectures are often postponed. The doctor kept a diary when I first went there. He put his name and the time id' his visits against the elate—nothing 'more. This diary has been, destroyed. No prescription-book is kept. Adjourned to 6th February, at 10 a.m.

Thursday, 6th February, [913. Charlotta Ludwig, examination continued. [Parcel of charts from the 31st March, 1912, to date, except those in actual use, put in.] To the Commissioner.] The parcel contains all the charts from the -"ilst March, 1912, to date, except those already produced and those in actual use. I think a few of them are not originals, but copies. The untidy ones were recopied and the originals destroyed. They were recopied, I suppose, because the originals were untidy. 1 remember several that I told them to copy out. No one else but myself destroyed the originals. I did it by tearing them and putting them in the waste-paper basket. All the books and things which have been destroyed have been destroyed b}' my authority and in the manner described. I have been in the home since March, 1910. Miss Bagley, who came in as locum before my arrival, started the diary for the Medical Officer. The keeping of the diary was continued till the diary was finished at end of 1910. The practice was then discontinued. It w 7 as discontinued because I did not think it was necessary. I did not consult the Inspector as to the destruction of charts and books or the discontinuance of the diary. [List of deaths and list of transfers to General Hospital put in. (Exhibit No. 61.)] The list of deaths is that of those occurring in the home from 1906. The list of transfers shows the transfers —(1) in my time, and (2) those prior to my time. Cross-examination by Mr. Skelton continued .] I could not tell you without looking it up how many confinements Nurse Jones had attended prior to Mrs. Chamberlain's. There is no record in the home showing what treatment was administered to Mrs. Chamberlain. The nurses' reportbook would show the treatment. The nurses' report-book containing Mrs. Chamberlain's ease has been destroyed. The principal items of the treatment were carried into the case-book. There is no record in the case-book of the medicines that were given to Mrs. Chamberlain, with a few exceptions. Part of the treatment is shown on the chart. The prescriptions already produced are the only prescriptions made out for Mrs. Chamberlain. The other medicines given to Mrs. Chamberlain w 7 ere stock medicines kept in the home, and given on Dr. Inglis's verbal instructions. When Dr. Inglis made his first examination of the patient he only prescribed salol and boris. That was, as far as I can remember, on the third day. That was for offensive breath. It is a kind of internal disinfectant. He said nothing about her nursing treatment. He left that to me. The next medicine he prescribed was the stock cough-mixture. 1 think it is a mixture of camphor and glycerine. I do not remember when this was ordered. I cannot say how many doses the patient had. As far as I can remember, that is all the medicinal treatment the patient had in the main building. I asked the doctor about the food on account of the continued high temperature, and lie told me to keep her on milk diet. She complained of the milk diet, and 1 asked the doctor if 1 could supplement it. I cannot say from memory how many perinaeums I sutured in Christchurch. Of the lectures in the book, none were postponed. They are not entered in the book till they have been given. Mrs. Chamberlain's was the first case of septicaemia that occurred here in my time. Mrs. Porch's is the only one since. I told Dr. Inglis that the stitches were sore. As far as I can remember, that was on the third day. 1 do not think 1 mentioned it to him again after that. Nurse Way was told off to attend to Mrs. Chamberlain and watch no other patient. Mrs. Chamberlain asked on more than one occasion to be allowed to sit up. I said it was not wise to do so. We do not allow patients with stitches in the perinaeum to sit up till the perinaeum is healed. She was never allowed to sit right up. Chamberlain did not betray any anxiety about his wife till it was time for her to get up. After that he became very anxious. I never heard Chamberlain say that he would put the matter in the hands of a solicitor if he could get no satisfaction. I heard his evidence that he threatened to consult a solicitor about the matter. When Chamberlain asked me 1 told him I could tell him nothing further than that his wife lias chest trouble, and suggested that he should go to the doctor. He did not want to go, and said that T could quite well give him the information without his going to the doctor. I think he did complain as to not being able to get any explanation as to his wife's condition. I reported to Dr. Inglis that Chamberlain was worrying me over the matter. I cannot remember the date of this. It was about the end of the first fortnight. I certainly say that Mrs. Chamberlain did not catch a chill on the labourboard. Notwithstanding that there are ten points which have been put to me, and which I have not got a clear recollection of, T still swear that Dr. Inglis saw Mrs. Chamberlain on the second day of the confinement. I cannot say how many times I spoke to Dr. Tngfis over the telephone about the cases; there were so many. I rang him up on the second day of the confinement. I cannot remember the next time I rang him up about the case. I last rang him up about the! ease on the night she died. Chamberlain came to me several times about Iris wife. I had two or three fairly long conversations with him. I probably told Chamberlain to go and see the

C. LUDWIG.

H.—sis.

doctor, and he would tell him what was wrong with his wife, i did not say that the doctor would " tell him straight. , ' I do not use the word " straight " in that way. To the Commissioner.] I only told Chamberlain about the chest complaint. That is all 1 know. 1 did not tell him she was septic. I did not know that. Dr. Inglis told me somewhere about the end of August that the patient was septic. That was after she was removed to the isolation ward. I do not think Chamberlain saw me after the removal to the isolation ward. He saw the nurse there. The only conversation I had with Chamberlain after his wife went into the isolation ward was as to the removal of his wife. When Chamberlain asked what was the matter with his wife I told him that Dr. Inglis said she had chest trouble. I had no conversation with Chamberlain after T knew that his wife was septic. I did not know Mrs. Chamberlain was septic when she was put into the isolation ward. I was quite indignant when it was suggested that she was septic. Dr. Inglis told me to put the patient into the isolation ward because of her continued high temperature. 1 had no suspicion then of septic trouble. I knew nothing till Dr. Inglis told me he was going to report it as septicemia. To Mr. Skelton.] I had no conversation with Chamberlain after I suspected that Mrs. Chamberlain was septic. 1 referred him to the doctor. There were two cases of septicaemia while I was in Christchurch—two patients in at the same time. I would not deny that Chamberlain visited the home on the 31st August. He may have said that he was not at all satisfied with the way things were going. 1 may have said that I did not think his wife was seriously ill. I do not remember him saying that we (the doctor and I) would have to get a move on, and get doctors in to hold a consultation. He told me once that he had seen Dr. Inglis. I cannot remember the date I heard that septicaemia was strongly suspected. I was so busy that I cannot remember that I had anything definitely in my mind to fix the date when Dr. Inglis first told me he suspected septicasmia. He told me he suspected the case was septic, and would report it as such, but I cannot remember the date. I do not think he ever told me definitely that it was a case of septicaemia. I wrote about the case to my Department at different times as the case went on. We always think of sepsis when there is a high temperature. The letter produced is one of that I wrote to Miss Maclean. [Exhibit No. 36.] It is dated 1 !tli September. I produce two others, dated 29th August (portion), and sth September. [Exhibits Nos. 34 and 35.] Cross-examined by Mrs. Nicol.] There were only two nurses present at the delivery of Mrs. Porch. Other nurses attended to her afterwards as well. Only those who were present at the delivery have their names in the case-book. Nurse Jakeman nursed her before the onset of the delirium. When she became violent all that were near her had to go to her. I cannot say the exact date when she became delirious. She became queer, and had to be watched on the second day. When I wrote " onset of the delirium " on the chart I referred to the violent attack. Nurse Jakeman was with the patient all through from the delivery till she went to the isolation ward. Nurse Brawn was put on when Nurse Adams left. Two nurses were in attendance on Mrs. Porch in the isolation ward —night and day nurses —but one would be called up to help the other when necessary. There was a nurse continuously with her before she went into the isolation ward. Mrs. Porch had a test taken in No. 6 and showed signs of septic infection before she went into the isolation ward. The swab was taken from Mrs. Porch about 6th September —or something like that. Dr. Frost took the swab. It was taken at Dr. Inglis's instructions. It is not my place to say what caused the delirium. Dr. Inglis ordered the injection of vaccine because of the result of the swab test, I think. Dr. Inglis gave the patient an intrauterine douche one day. I cannot say why it was given after the injection of the vaccine. I do not suppose the douche was given on account of the insanity. It was, as far as I can remember, the third evening or fourth morning that Mrs. Porch was moved to No. 6. I could not swear to it. No vaginal examination was made when the temperature rose. It was for the doctor to account for the rise in temperature. Dr. Goldstein was there twice a day to see the patient. I think Dr. Inglis's first visit after he came back was on a Sunday. The patient was sent to the General Hospital because Dr. Inglis told me he had found a pelvic abscess which would need opening, and he could not do it at St. Helens. Nurse Brawn came on in the place of Nurse Adams in the isolation ward. Nurse Jakeman did nothing in the home but attend to Mrs. Porch. I have been taught that puerperal fever is an infectious fever. There are not two labour-beds in the home. There is a labour-board and a table which has been used at times as a labour-bed. Women have often been confined in the bathroom. 1 have not sent women away because labour has not been advanced far enough, and they have had to be confined in their own homes. Nurse Brawn was a general trained nurse. She was training at the home for midwifery. To the Commissioner.] As far as I know, Mrs. Chamberlain was alone in No. 9 ward, but I cannot swear to it. From there she went to No. 3, a single ward. From there she went to the isolation ward. The books will not show what particular wards the patients were in on a certain date. Mrs. Cartledge was in the home. Her baby was born on the 28th August. She was transferred to the General Hospital on the Ist October. Mrs. Blown was not transferred to the General Hospital. She was in the home, and her baby was born on the 31st August. She was discharged on the 21st September. I cannot tell you when the entry in the case-book was made. I can vouch for its accuracy as far as I know. To Mrs. Nicol.] Hot fomentations were put on Mrs. Chamberlain's nipples because they were sore, not to drive the milk away. To the Commissioner.] Those cases in August and September were the only cases —those with the temperature. Some time after Mrs. Chamberlain's case the laundress and some of the nurses had bad hands, 1 cannot say what caused them. There was no general epidemic. To Mrs. Nicol.] Dr. Inglis put in the sutures in Mrs. Cartledge's case. The abscess was caused by a blow against the corner of a table she had before she came in. It had nothing to do with the stitches. The bed-pans are given at certain times, but they are also given at any time when the patient requires them. There are always nurses about to give them.

67

H.—3lb.

68

[O. LUDWIG.

To the Commissioner.] I have never heard any complaint about the patients not getting the conveniences they are entitled to. No book is kept where complaints can be entered. One patient complained to me that the nurse refused to give her a pan. I inquired into it. I could make no headway, as the nurses said they had given her pans whenever she required them. The patient told me the name of the nurse. This nurse told me that she had told the patient she must have the pan at stated times. That is the only complaint I heard on the matter. The nurse was a new one. I spoke to her on the subject, and heard no more complaints. It is certainly the duty of the nurses to give the pan when asked for. To the best of my belief, this duty is carried out. The incident I have referred to occurred about a year ago. We sent a number of cases to private hospitals, on Dr. Goldstein's advice, between the 2nd September and the 15th September, I think. We took in tw 7 o during that time that we were unable to transfer because of want of time. We arranged for nine patients to go elsewhere. I think I started taking in patients again from middle of September. I was told by Dr. Inglis when it would be safe to start taking patients in again. In the meantime every room was thoroughly disinfected. It was done by the nurses. We got the Health Department to fumigate after the death we had in No. 3. That was early in October. I think I reported Dr. Goldstein's suggestion that the home be closed dowm for a few 7 weeks. There were no septic cases after the disinfection. Mrs. Porch's was the last. Re-examined by Mr. Mays.] I had a four months' course under the Central Board of Midwives in England. The period of training for a pupil midwife in New Zealand is twelve months. The period of training in midwifery for a nurse who holds a certificate in New Zealand is six months. In doubtful cases it is the rule at St. Helens for one nurse to be told off to attend and wash one patient only. By doubtful cases I mean those of continued high temperature. A pupil nurse must have twenty deliveries and twenty after-treatment cases before she is permitted to qualify. The length of training of nurses and pupil nurses in midwifery is fixed by section Bof the Midwives Act, and not by regulation. In entering up the case-books from time to time 1 keep the history of the case by me till this is done. The disinfection and fumigation of wards is part of the training of pupils. They are taught how to do it. The number of patients for whom it is necessary to have a special prescription is very small in comparison wdth the number of patients. The Medical Officer gives the prescription. Medicine is not given without the approval of the Medical Officer. We have stock mixtures. I give aperients without the doctor's directions. The doctor came in from the isolation ward and told me that he was sending in a notification as to Mrs. Chamberlain. That w 7 as the first I knew of sepsis. So far as I remember, the subject w 7 as not brought up before —that is, the subject of sepsis. Hannah Jones (called by Mr. Mays), on her oath, saith. I am a pupil nurse at present in training at St. Helens. I have been a pupil nurse for ten months. I was present at the confinement of Mrs. Chamberlain on the 11th August last. Under the Matron's guidance I did some of the manual work of the confinement. The labourbed consisted of a mattress, a blanket on top, a macintosh covering, a sheet, a draw 7 -sheet macintosh, an ordinary draw-sheet, which the patient lay on, then a sheet, a blanket folded in three, and a draw-sheet over that. There was nothing abnormal about the atmospheric temperature or conditions that I am aware of. There was nothing abnormal about the confinement. Mrs. Chamberlain complained of nothing during the labour that I can remember. I observed nothing to indicate that she had caught a chill or cold during labour. 7he patient did not become wet to the armpits that 1 know 7 of. I attended her once after the labour was complete —an hour or tw 7 o after. She told me she had a very cruel mother, who had been staying with her for seveial weeks, with a bad leg, and just when she was needing her most, she left her. She made no other complaint to me. I do not think I attended her at any other time during her stay there. I noticed Mrs. Chamberlain's cough all through. She said nothing in my hearing about her cough. I did not see her when she came in. I noticed nothing special about her. when I first saw her. Cross-examined by Mr. Skelton.] I commenced my training at St. Helens on the 17th April. I had attended six deliveries up to Mrs. Chamberlain's. I did not do all the manual work in all those. I do not remember which or when w 7 as the first case when I did all the manual work of the delivery. Ido not think there is any specified number of deliveries at which a nurse has to be present before she is allowed to do the manual work. I did not do all the manual work in Mrs. Chamberlain's delivery. I did the work, the Matron guiding my hand. The Matron did the actual work of delivery. We took the ordinary precautions against anything abnormal happening—that was, retarding the head, which probably the Matron and I did—l cannot be sure. I do not remember anything else. I do not remember how long the head was retarded. I know the object of retarding the head. It is to allow the perinaeum to stretch, and also to avaid a rupture of the perinaeum. Retarding the head means retarding the delivery. I remember that the perinaeum was ruptured. I cannot say how 7 long the head was retarded. The longer it is retarded the less the chance of rupture of the perinaeum. I do not remember the length of the rupture. It was not extensive at all. I know the table in the bathroom. I do not remember how many women were delivered thereon in August last. I do not remember any. Three or four have been delivered elsewhere than on the bed I have described during the time I have been there. I know that the labour-bed in Mrs. Chamberlain's case was just made in the usual way. I could not deny that Mrs. Chamberlain w 7 as wet to the armpits when on the bed, but I have no recollection of it. Ido not remember her shivering wffien she was removed to the bed. Probably before the delivery the Matron was in and out of the room. The patient was not under chloroform. The Matron may not have put a hand on the patient herself but on the child. I do not remember all the circumstances and steps of Mrs. Chamberlain's delivery perfectly. I say it is not possible that during the delivery the Matron was in and out of the

69

H.—3lb,

H. JONES,

room. I do not remember talking to the Matron at the door. 1 do not remember going to see her with reference to something that had happened in the case. If the Matron said, " You should not have done that," I do not know to what it referred. It might have been said to me, and it might have referred to one of the most trifling things. It is not true that the Matron did not have charge of Mrs. Chamberlain actually till she put in the stitches. I cannot remember very much about this case of Mrs. Chamberlain's, but I say the Matron has never left me during the time of a delivery. 1 saw Mrs. Chamberlain again, though 1 was not in attendance on her. I cannot say when I first saw Airs. Chamberlain after- her admission. I cannot from memory tell the time she w 7 as put on the labour-bed, Ido not remember whether it was cold or warm on the morning in question. I do not remember when I first noticed Mrs. Chamberlain cough. I would probably see Mrs. Chamberlain a week after her confinement, She had the cough from the beginning. I do not know when I first noticed it, I remember hearing her cough while she was in No. 9. She was there for some days. I believe it was on the day of the confinement that I noticed the cough first. I may be mistaken. It was a deep sort of a cough. I will not be sure, but I think it w 7 as. I do not know 7 much about coughs. I trive it up. I cannot say whether it was a deep one or not. I still say that I believe 1 heard Mrs. Chamberlain cough in No. 9, though there may have been as many as thirty people in that room since, probably ten w 7 ith coughs. I cannot tell you one of the ten. I had two patients in No. 9. Neither of these had coughs. I do not think I am mistaken in saying that I remember Mrs. Chamberlain having a cough on the first day in No. 9. I could not from memory tell the name of the patient at whose delivery I assisted before Mrs. Chamberlain's. I cannot remember much about Mrs. Chamberlain's case to tell you. Probably the Matron guided my hands. Ido not remember taking any very important part in the delivery in any case before Mrs. Chamberlain's. I cannot remember if 1 took as important a part in the delivery of any patient prior to Mrs. Chamberlain as I did in her case. I still say that, in spite of my loss of memory, I heard Mrs. Chamberlain cough in No. 9 on the day of her delivery. A cough is a rare thing. It might have been a cold that Mrs. Chamberlain was suffering from. I cannot remember how long after she was put in No. 9 that I heard the cough, but 1 think it was the same day. [Mrs. Nicol does not cross-examine.] Re-examined by Mr. Mays.] Patients do not often shiver after labour. If a patient shivered slightly I would not regard it as a fact worth remembering. My memory is not good enough to enable me to give details of what takes place in every normal confinement. T am doubtful as to my evidence in the cases where I have said " I believe" and " probably." The table in the bathroom is used when there is no time to get the patient to the labour-room. To the Commissioner.] I have not a very distinct recollection of Mrs. Chamberlain's case. 1 cannot recollect Mrs. Chamberlain's features. Ido not know w 7 ho prepared the room. 1 think I was called up to the case about 3 in the morning. 1 do not remember how many hours she was on the bed before delivery. I was not there all the time. The night nurse was probably there when I was away. The patient was already on the bed when I went into the room. I cannot say how many hours 1 was in there with her. My recollection of the circumstances of the confinement is not very clear. Tracy Russell Inglis (called by Commissioner), on his oath, saith. I undertook to get Mrs. Brown's chart from the Hospital. I rang up the Hospital from the house next door here. I told Dr. Maguire that we required' at the inquiry the charts of Mrs. Cartledge and of Mrs. Brown. He asked, "Which Mrs. Brown?" I said, "Mrs. Sidney Brown, who was in ward No. 16." These charts came down this morning. Another chart has now been produced relating to Mrs. Brown. I do not know, but have an idea, why the last was not sent down this morning. It is absolutely untrue that this chart was not sent down this morning through my wilful fault. Cross-examined, by Mrs. Nicol.] 1 was not aware that Mrs. Brown was in the Hospital in October. To the Commissioner.] 1 did not know that Mrs. Brown was admitted to the Hospital on the 6th October, 1912, and was discharged on the 16th November. I know she was admitted on the 22nd November, but I did not know that was a readmission. She was then under my charge. 1 did not know she had been in Auckland Hospital from the 6th October to the 16th November. I first learnt of that to-day. I assert absolutely that I did not know till to-day that Mrs. Brown had been in the General Hospital from the 6th October to the 16th November. The chart shows that she was then under Dr. Robertson. She was in a w 7 ard I never go to except on request. Cross-examined by Mrs. Nicol.] I operated on Mrs. Brown in November. 1 did not know anything about her being in the Hospital in October. To Mr. Mays.] In the first instance, Mrs. Brown was in the medical ward. I only go in there at request. During Mrs. Brown's first sojourn there she was treated medically—there was no operation. The second time was a surgical case. That is how it came under me. To the Commissioner? It is generally put on the second chart that the patient has been in before. As there is a complete history on the second chart I did not ask anything about the patient. To Mr. Mays.] When I operated Mrs. Brown was suffering from trouble of very long standing in the tubes and ovaries. This trouble did not arise from nor was it in any way connected with her treatment at St. Helens. The trouble was of at least two years' standing, probably longer. Mrs. Cartledge had a suppurating bursa over the hip-joint. That is why she was sent to the General Hospital. She attributed it to a fall or a knock some time before. It had nothing to do with the confinement, I advised her not to have it attended to till after she got home.

H.—Blb.

70

T. B. INGLIS.

Gross-examined by Mrs. Nicol.] I do not think anything in the way of a curative treatment could have been done to Mrs. Brown at a previous confinement, My attention was drawn to it because the patient had complained of pain. It would not come under my domain to attend to the ovaries and tubes at a previous confinement. I do not know if Nurse Boyd was sent down to St. Helens from the General Hospital. I believe she was trained and got her midwife's certificate at St. Helens. It is not true that women who come to St. Helens with complications are sent to the General Hospital. I did two caesarian operations at St. Helens. I sent one caesarian operation to the Hospital. There was a special reason for it. It is not a practice at St. Helens to send complicated cases to the General Hospital. We are never without trained and registered nurses at St. Helens. [Mrs. Nicol says she wishes to withdraw 7 the statement alleged to be made by her, and recorded at top of page 36. She says that she may be able to bring evidence that the books were destroyed in connection with this inquiry.] Susie Way (called by Mr. Mays), on her oath, saith. I am a pupil nurse undergoing training at. St. Helens. I recollect Mrs, Chamberlain. I have been eight months at St. Helens. I am a single woman. I undertook the nursing of Mrs. Chamberlain from the first day of her confinement till Nurse Adams took charge of her. She was in No. 9. [Mr. Skelton asks that the evidence of this witness be excluded on the ground that she was sitting in Court during the examination of other witnesses, contrary to the order to witnesses to leave the Court. Witness states that she did not know of the order. Commissioner decides to take the evidence subject to comment.] I noticed the patient's quick respiration and her cough. The cough was a chest cough. The senior nurse on duty marked the chart in pencil, and I marked it in ink each morning. The chart already produced is the original one. The cough continued all the time 1 nursed her. Mrs. Chamberlain complained about her cough keeping her awake at night. She was very depressed all the time I was nursing her. I asked her the reason. She said there were home troubles, and complained about her mother leaving her. She thought it very hard of her mother to leave her after all she had done for her—nursing her with a bad leg before she came into the Hospital. Mr. Chamberlain came at times to ask after his wife and the baby. 1 referred him to the Matron, He said he was thoroughly satisfied with the treatment 1 gave his wife. While nursing Mrs. Chamberlain I attended no other patients. After handing the patient over to Nurse Adams I was sent away to be isolated. I w 7 as aw 7 ay four days. I had a lysol bath, washed my hair in lysol, and returned to the Hospital with no clothing that 1 had worn in the isolation ward. I was not present at the confinement of Mrs. Chamberlain. Mrs. Chamberlain made no complaints to me other than about the cough disturbing her at night. One morning when I was sponging her she complained of a pain in her right side. I told the Matron, and the doctor examined her. He asked her if it hurt her. She said " No." After he had gone she said she had had him, because it did hurt her and she did not let on. Cross-examined by Mr. Skelton.] She made no other complaints to me. She said nothing about the stitches. Chamberlain did not tell me that he intended to have his wife's body embalmed. Re-examined.] I noticed the stitches and the condition of the perinaeum. It always looked very healthy. Gross-examined by Mrs. Nicol.] I was a day or two over a week with Mrs. Chamberlain. I was the only nurse there. We have our regular duty there. Our hours are eight, I slept next door to Mrs. Chamberlain. I used to go in to her several times during the night. I had the baby to attend to as well. I had it. night and day. I felt capable of doing it all. I did not complain nor think that I was being overtaxed. It was in the isolation ward. I did not feel my strength go down at all. It was trying at times, owing to the baby. Martha Broadley, recalled by Mr, Mays, saith. I was not present at Mrs. Chamberlain's confinement. I did not attend or nurse her in any way. I had conversations with her occasionally, but she would not speak w 7 hen she was spoken to.' She mentioned about having a cough and a pain in her side. That was in the second week. I did not see her before that. She told me that she had not been well before she came in— that she has been nursing her mother. On one occasion I had a conversation with her husband. That was when the patient was in the isolation ward. He asked me if his wife was very ill. I said, Yes, she w 7 as. He asked me if her temperature were 105. 1 said .1 did not know, and told him there was a trained nurse in attendance. He asked me what was her rapid breathing due to before her confinement, I said it might probably be some chest trouble. He said she had not had chest trouble. He said his wife was overworked with nursing her mother, who was a very heavy woman; that she had dressed the leg he did not know how many times, and the mother was a very heavy woman to move about, and it made his wife very tired. I remember no other conversation. We had three trained and registered nurses in the Hospital last term, and we have two this term —all we can accommodate. There are many trained nurses waiting to come in. They jump at the chance of coming in. There are a great many applicants. When a trained nurse is on duty she is always responsible for taking the temperatures and leadpencilling it on the charts.' If there is no trained nurse the senior nurse is responsible. No pupil nurse is allowed to mark temperatures on the chart till she had been there at least six months. In general hospitals they take temperatures and note them down in less than a month. Mrs. Chamberlain never complained to me about her physical condition, with the exception of the cough and the pain in the side. I examined her abdominal region. It was slightly distended. That happens to any one lying on the back. She was relieved by enemas. The uterine discharge was quite normal,' with the ordinary smell after a confinement. I felt the uterus.

M. BBOADLEY.I

71

H.—3lb.

It involuted normally. 1 did not examine the perinaeum. I have seen many cases of general sepsis in the General Hospital—maternity cases. Up to the 28th August I thought Mrs. Chamberlain was suffering more from the chest, than anything else. She did not have one symptom of septicaemia. Cross-examined by Mr. Skelton.] I did not see her till the second week. I saw her after that every day till she was removed to the isolation ward. I know the signs of septicaemia. It is always ushered in with a rigour, high temperature, rapid pulse, suppression of lochia, milk secretion lessened, furred tongue, headache, and feeling ill. The leading signs are the rigour, high temperature, and rapid pulse. Cross-examined by Mrs. Nicol.] 1 do not know who prepared Mrs. Porch for her confinement, To the Commissioner.] 1 attend outside cases. If I am engaged when a case requires me a nurse is sent along, and then 1 follow her up. Occasionally, cases are attended by uncertificated nurses outside. Only the senior available is sent, and one who has attended a number of cases. The nurse does not stay in the house. She attends at the confinement and for ten days after. She goes backwards and forwards for ten days. She only stays all night with the patient if necessary. They attend in that way when no medical man is called in. Temperature and pulse is kept in a note-book. If the patient has a temperature they keep a chart. I enter outside cases in a separate case-book. Anything abnormal in an outside case at which lam not present is rung up to the Matron, and she rings up Dr. Inglis. In some cases they prefer their own doctor. There have been no cases of septicaemia outside among my patients. If there were one the nurse would be disinfected and sent away. She would not be allowed inside the Hospital. She would be sent away for four or five days. Re-examined, by Mr. Mays.] The pupil nurses very, very rarely have a case on their own. i follow 7 up as fast as possible. Cross-examined by Mrs. Nicol.] I do not remember the case of Mrs. Rands, or if she was sent away and had to be confined at her own home. If it were twelve months ago it would be before my time. Adjourned to 7th February, at 10 a.m. Friday, 7th February, 1913. Re Mr. Stevenson's Charges. Tracy Russell Inglis (called by Mr. Mays), on his oath, saith. Ido not recollect Mrs. Stevenson personally. According to the case-book she was admitted to the home on the 11th May, 1912. Case 1259 —case-book. The day after Mrs. Stevenson left the Matron communicated with me. The case had been a normal one, and there are no notes further than the entry. I saw every patieut in the home during the time Mrs. Stevenson was there. I have no recollection of any complaint being made by Mrs. Stevenson. Had there been anything in her condition requiring my attention I would have remembered the case. The Matron communicated with me the day after Mrs. Stevenson left, and said that Mrs. Stevenson had sent for a nurse, and that a, nurse had gone to the house where she was staying, and that the nurse had advised her to send for a medical man. The next day the Matron told me that Mrs. Stevenson had been moved to the General Hospital. She asked me to make inquiries as to what was wrong with Mrs. Stevenson. I did so, and w 7 as told she was suffering from pulmonary embolism. I did not see her in the General Hospital that I know of. 7 T o the Commissioner.] I have no note that I saw Mrs. Stevenson particularly. Her case was quite normal, and there was nothing to cause me to remember it. I did not specially authorize her discharge. Normal cases are discharged as their time comes up. I did not give formal consent to her discharge. My authority is given to the Matron to discharge in all normal cases. The Matron may have asked me if the patient could be discharged. I do not remember her doing so. I cannot speak of my own knowledge as to her condition on discharge except that there was no abnormality. I think I can sw 7 ear that on the day of her discharge she was fit to be discharged. T had been right round the Hospital. I do not know wdiat room she was in. During the time she was in the home I cannot say that T remember her being in any ward or room. All I can say is that my attention was not directed to her as being abnormal, and that I went right round the Hospital and saw every patient. To Mr. Mays.] The pulmonary embolism are small clots carried from the uterine sinuses to the lungs or from other veins to the lungs. Tt is an absolutely sudden illness. The first sign you get is the pulmonary embolism. There is no warning. Patients sometimes recover, but it is a very serious illness. Other clots may be carried to other parts of the body, even to the brain. Having reached the brain they may cause paralysis, or insanity, or death, or any two or three of these things. Ido not think that this disease can be guarded against during confinement, except that as any sudden movement might cause it we generally tell the patients to be careful. It is a comparatively rare disease. It is one of the unexpected things that follow a confinement, To the Commissioner.] I do not remember if I consented to the usual period following the confinement being shortened. Patients are often discharged earlier at their own request. In Melbourne there is a rule that patients have to go out on the tenth day. I do not think that the room leading on to the balcony is the best of rooms to place a woman in after her confinement, but T do not think there is any harm in it. It may be a little more rowdy. I, should not say it was a very suitable room, but I do not think any harm could result from it. I do not know what room the patient was moved to. Cross-examined by Mr. Stevenson.] I visited the home on eight days while Mrs. Stevenson was there. I saw her on each day. At least three times a w 7 eek Igo right round the Hospital,

H.—3lb.

72

[t. c. inglis.

and see every patient in it. If I w 7 as at the home on the day your wife came out I saw- her, but I am not sure that I did. I have no distinct recollection of ever seeing Mrs. Stevenson. I was in the Hospital twice on the 24th May. I was also there on the 23rd May. Ido not know the conditions of Mrs. Stevenson's heart. I would not examine it, unless a complaint was made. [Mrs. Nicol says she dees not wish to question the witness.] Re-examined by Mr. Mays? The chart produced of Mrs. Stevenson shows an absolutely normal condition. Gross-examined by Mrs. Nicol.] The respiration is not taken unless there is some abnormality. The space for respiration on the chart is for abnormalities. They were probably taken the first day and then discontinued because there was no abnormality, There is absolutely no reason for taking the respiration unless there is an abnormality. To the Commissioner ,] I have never asked the nurses to fill in the respirations unless there is some abnormality. Charlotta Ludwig, recalled by Mr. May. I have a general recollection of Mrs. Stevenson's confinement. From the books 1 see that she was admitted on the 11th May. To the Commissioner.] She was discharged on the 23rd May. That is within the period of fourteen days. I said she could go. She asked herself to be allowed to go. The Medical Officer did not specially shorten her period of detention. He gave me general authoritv 7 . He has given me a general authority where eases are perfectly normal. He did not give me a specific authority in this case, I discharge all normal cases without reference to the doctor on the general authority given by him to me. Mrs. Stevenson was not examined by the doctor before her discharge. She was put in the little room off the balcony—No. 3. I believe she was moved from there to No. 2, a room containing three beds. I expect that it is correct she was moved after four or five days. There may have been tw 7 o other patients in No. 2. To Mr. Mays.] The condition and progress of the patient from the beginning to the end was absolutely normal. When she asked to be allowed to go she said she felt quite well. Miss Broadley and I w r ere both present, and said good-by to her when she left with some lady. I saw nothing at all extraordinary about her. She made no complaint wdiatever while in the home, but, on the contrary, was most grateful for the attention she had received. The next day some one rang up and asked if the nurse could go and see Mrs. Stevenson. A nurse was sent. I think it was Nurse Clare. She is not now at the home. Nurse Clare came back and described the woman's symptoms to me. They were that the patient was sitting up in bed looking very ill, breathing was very difficult, and the patient was very blue, pulse about 160. She said siie had. advised that a doctor be got at once. I have seen two cases of pulmonary embolism. The attack is very sudden and the symptoms very acute. In one case the patient died a few minutes afterwards. There were no symptoms at all at any.time w 7 ith Mrs. Stevenson to warn me of an attack. The chart already produced is the original chart of the case. Cross-examined by Mr. Stevenson.] I noticed nothing unusual at all about your wife when she went away from the home, or just before. I did not know anything about the condition of her heart. I did not know that her heart was w 7 eak. I did not examine it. It is not in my province. Ido not know how many times Dr. Inglis visited the patient. She was not examined that I know 7of by the Medical Officer. I saw 7no necessity whatever for her examination. It is not at all usual to have the patient examined by the Medical Officer in normal cases. When discharged she appeared to lie in quite good health. She was a little nervous wTien she signed the receipt. I made a remark on it, and she said she was excited at the thought of going home. There was absolutely nothing in her condition to arouse in me any thought that she was not fit for discharge. The child was in good condition, too. To the Commissioner.] I seldom make notes in the case-book when the case is absolutely normal. The patient had no cold when she left the home. To Mr. Stevenson.] I cannot account for the patient's condition when she went to the General Hospital the day after her discharge. There is no general examination of the patient when she comes in. The heart is hot examined. The patient comes in for confinement. Unless there are circumstances which call for the Medical Officer's opinion I do not call him at all to any specific case. I should not have thought it necessary that patients should be subjected to an examination as to their general health wdien they come in. If they tell me they have been under a doctor, or are suffering from any disease, I always get the doctor to see to them. Re-examined by Mr. Mays.] I always ask the patients as to their general health. If there is anything worthy of notice I inform Dr. Inglis. Steps are then taken to safeguard that trouble during confinement. Mrs. Stevenson never mentioned the words "heart trouble" to me. Cross-examined by Mrs. Nicol.] I do not remember if Mrs. Stevenson's flannels were taken off. They may have been. No patient is made to take off flannels. It is for them to say whether or not they will w 7 ear them. I have been trained to know when there are complications. It is not a complication when the baby is born in the bathroom. Labour is not complicated thereby. No babies have tumbled on the floor in my time. William Norman Abbott (called by Mrs. Mays), on his oath, saith. In May of 1912 T was Resident Physician at Auckland Hospital, I am still such. I recollect Mrs. Stevenson being admitted to the Auckland Hospital on the 24th May, 1912. The chart produced is hers. When admitted she was suffering from embolism of the lung—that is, small portions of clot would get broken off and carried along in the blood-stream, and get stuck in the small vessels of the lungs. The patient finally got better from this condition. Vfter that she became quite insane, and was very noisy, ami had to be transferred to another

73

H.—3lb

W. N. ABBOTT

ward. As far as I know, the patient was sent to the Mental Hospital at Avondale. I understand that she died there. There were no signs of pneumonia about the patient when she came in. In a quick general diagnosis one might easily mistake embolism of the lungs for pneumonia in the early stages. There would be no warning of the condition till the embolism actually occurred. I see the maternity chart already produced. I should say it was a normal chart. There is absolutely nothing therein to warn a medical man of any heart trouble or embolism. In my opinion, it would have made no difference had Mrs. Stevenson been kept in the home for another day or two days. It is generally believed that the cause of a clot breaking off is a sudden movement. It is a rare disease. The only thing to guard against it in confinement cases is for the patient to stay in bed for the proper time. Cerebral embolism would cause insanity and death. Cross-examined by Mrs. Nicol.] Mrs. Stevenson was certainly not in a normal condition when she came into the General Hospital. She was suffering from embolism of the lungs, and not from double pneumonia. In an ordinary surgical case with no abnormalities respirations are not charted. Cross-examined by Mr. Stevenson.] Embolism is quite a separate thing from and not what people ordinarily call pneumonia, I may have told you that the case was sent in by Dr. McDougall as one of pneumonia, The complaint (embolism) might come on in a fraction of a second. Re-examined by Mr. Mays.] I understand that the case was sent in by Dr. McDougall as one of pneumonia. I would not find any fault with that diagnosis for the purpose of ascertaining if a patient w 7 as ill enough to send to the Hospital. Looking at the maternity chart, I see no reason for continuing charting the respiration after the first one or two. If Mrs. Stevenson's chronic cardiac disease had any effect in bringing about the embolism it would be very indirect. Had Dr. Inglis known of the cardiac condition I see nothing that he could have done to have prevented the subsequent embolism. Bridget Carm:ody (called by Mr. Stevenson), on her oath, saith. I am sister of the late Mrs. Stevenson. I live with my husband at 43 Richmond Road, Auckland. I remember my sister being in St. Helens for her confinement. At that time she was living at Avondale. I saw her the day before she went into the home. She came to see me at my place. She went into the home early the next morning. I saw her in the home on, I think, the sixth day. I was not allowed to see her till then. I saw her once after that, w 7 hen I went with a friend to bring her home. She sent word by her husband that she w 7 ould be out the next day, and asked if I w r ould go for her. I w 7 ent about 2 the next day, accompanied by Mrs. Poole. We brought her away. She was ready to come when we got there. She was ready to come, and said she did not think they would have allowed her out as it was not a very nice day. She said she would have been disappointed if I had not come. I took her to my house, as her own place was too far for her to go. I then lived in Newton Road. She was to go on home next day. She seemed very shaky when w 7 e brought her away from the home. She was of an excitable nature. All night there was a wheezing on her chest. You could hear it quite plain. I got up before 5 next morning to attend to her. She seemed to be getting very bad. She never slept all night. It first came to me that she was ill through the night. I wanted her to go to bed when she got to my place, but she would not go then. She went early in the evening. I first thought she w 7 as really ill early in the morning, when she asked me to get her a drink. Up to the time she went to bed she was not very bright —she did not seem too well. She told me she could not get her breath. We rang up a lot of doctors. A nurse from St. Helens came first. Dr. McDougall came later. We had sent for the nurse at the suggestion of a neighbour—Mrs. Brett. We had sent for a doctor before the nurse came. My sister made no complaint as to her treatment at the home. She said the nurses were all very good to her. Cross-examined by Mrs. Nicol.] My sister always seemed to be a bit short-w 7 inded. That was before she w 7 ent to the Hospital. To the Commissioner.] The nurses ordered her to take maltine. Her husband got this for her. She was not very robust naturally, though she seemed well enough up to that time. She was not a very strong woman. She had been ill a year before. Dr. Robertson said she had a very weak heart. She did not complain about the Hospital. She said they had all been very kind to her there. Cross-examined by Mrs. Nicol.] I did not know her to be ill in her married life except on the one occasion. She had had rheumatic fever when a girl. She got over the miscarriage she had all right. Re-examined by Mr. Mays.] We walked to my home, which is half a mile or more from St. Helens. It had been raining in the morning. Mrs. Stevenson was well wrapped up. She said she was glad she was out. She wanted to get out. She w 7 as excited at the prospect of coming home. This showed itself —she trembled a bit. She complained of no trouble with her heart while she was at St, Helens. When I saw her before she went in and on the sixth day she was all right. Both the Matron and the submatron saw her leave. She held my arm while w 7 alking slowdy to my home. Cross-examined by Mrs. Nicol.] I saw Mrs. Stevenson twice at the home. I did not talk very long with her, as she had other visitors. We went home down the dip past the King's Theatre. There is just a slight rise past that. Martha Broadley (recalled by Mr. Mays), saith. I recollect Mrs. Stevenson being in the home quite well. Her case was absolutely normal. She was cheerful and most grateful, and w 7 as a very nice little patient. I was sitting in tke

10— H. 31b.

74

[m. broadley.

H.—3lb.

office at the time she left the home. I spoke to her. She was a bit shaky, not at all excited. They are usually a bit shaky when they go out. I considered her quite fit to leave the home,' I could not say what day she got up. I am sure she had been up two or three days before she left. I do not recollect what sort of a day it was when she left. Cross-examined, by Mr. Stevenson.] Mrs. Stevenson was on maltine and cod-liver oil. That is a usual thing to give the patients when they cannot feed their babies. If the mothers cannot feed their babies the babies are fed alternately artificially. The fact that the baby did not gain in w 7 eight by the time it went out is nothing. As long as they do not lose it is a sign that they are progressing. For the first twenty-four hours a healthy new 7 -born baby is fed every sixhours, for the next twenty-four hours they are fed every four hours; after that, if the milk is established, the baby is fed every tw 7 o hours during the day and every four hours during the night. I certainly do not think that the child should be fed more than two-hourly when both mother and child are healthy. It is incorrect that two windows were open in the room. The two windows are open only after fumigation, and there are no patients in the room then. I do not believe that you found two windows in the room open at the same time. The flannels, if they were off, must have been taken off at the patient's request. She may have said they were too hot. If off, they could have been put on again hadthe patient so asked. I knew the condition your w 7 ife was in when she was discharged. I should say she was never a very robust woman, but she was quite in a fit state to be discharged. The patient was absolutely abnormal at St. Helens. Questions are asked of every patient as to their health. We only take the temperature and pulse when they come in, but do not sound the heart, William Oliver Stevenson, on his oath, saith. lam a railway porter, on relieving duty at Pukekohe. I made complaints as to St. Helens, not so much about the treatment as about the w 7 ay in which she w 7 as discharged. I honestly believe I have ground for complaint. I was working at Avondale when my wife was discharged. I last saw her before she came out on the night before. She wanted to come out, but she did not like to think she was a trouble to any one. She expressed a desire to come out, but I told her not to come before a fortnight. She expressed herself to me as very grateful to the nurses for wffiat they had done for her. She wished to come out next day, and sent a message by me to her sister to come for her. I gave her sister the message, and arranged with her to go next day and bring my wife out. She was brought out. I do not suggest that she would not be allowed to remain in the home for the fourteen days. My complaint is that she was not fit to be discharged. I thought, from several visits I paid to her, that she was not fit for discharge. She appeared to be under a sweat, and weak and ill-looking. She had not her flannel on. I tried to impress on her not to be in a hurry to come out. I consented, against my wish, to her coming out. I did it to please her. I left the matter of her fitness to the Matron's discretion. I did not consult the Matron about my w 7 ife coming out. I took it this way : that if the Matron said she was fit to go she w 7 as fit to go. My wife told me two or three days before that she thought she would be out on the Thursday. I toid her to wait till the Saturday. When I went to tell her sister to go for her I thought the Matron had already consented to my wife's coming out. I got a telephone message at New 7 Lynn, and came in straightaway, and w 7 ent to my w 7 ife's sister's place, where I saw my wife about 11.30 a.m. I saw that she was in very great suffering. The nurse had been before I got there. I did not see her. Dr. McDougall arrived about 1.30. This was on the day after my w 7 ife came out of St. Helens. Had she not taken bad my wife was to go home on the Saturday. Dr. McDougall, when he saw her, ordered her removal to the Auckland Hospital. I took her there. I have heard the evidence of Dr. Inglis, Dr. Abbott, and the submatron as to what my wife was suffering from, and that the trouble was one which comes on suddenly. The medical evidence lias fairly satisfied me, but I still think there must have been some slight complaint to bring on the trembling. I was married on the 2nd June, 1909. My wife had enjoyed fairly average health. She was not so very robust. She only had a doctor once. She had some trouble with her breath at times, especiaily when she had a cold. I do not think my wife should have been discharged under the fourteen clays. I consented to it because I understood she was coming out with the Matron's full consent. Cross-examined by Mrs. Nicol.] I did not ask for my wife to come out. She did it. I believe my wife came out because she felt that her room there was wanted for other patients. I take it that the Matron gave permission to my wife to come out. The baby only lived five weeks. I think it was underfed. It was taken to Mother Aubert's Home, Mount Eden. Gross-examined by Mr. Mays.] I see by the book that the baby gained f lb. in the home. There was nothing noticeably wrong with my wife the night before she left the home, only that she was excited. She was of an excitable nature, and the prospects of getting out might have increased it a little bit. I do not say that that alone would be sufficient to justify the Matron in saying she was not well enough to leave the home. Right up till to-day T thought my wife had contracted pneumonia. Gross-examined by Mrs. Nicol.] I understood, from wffiat Dr. McDonald told me and from wffiat Dr. Abbott told me at the Hospital, that my wife was suffering from double pneumonia, Neil McDougall (called by Mr. Stevenson), on his oath, saith. I am a duly-qualified and • registered medical practitioner, practising in Auckland. I remember being called by Mr. Stevenson to see his wife on, I think, the 24th May. I saw 7 her in bed in a house in Newton Road. I did not thoroughly examine her. I examined her heart and felt her pulse. I concluded that her condition w 7 as desperate—that she was very ill indeed. 1 did not attempt to make an exhaustive examination of the condition of the chest on account of her serious condition of health, and also that I wished to conserve her strength for removal to the Hospital, I recommended her removal to the General Hospital, and wrote out a note

75

H.—3lb

N. McDOUGALL.I

there and then. 1 did not think she could be treated to advantage where she w 7 as; her heart condition was so serious. I formed the opinion at the time that the heart-disease was of old standing, such a condition as might follow rheumatic fever. I also thought at the time it was a peculiar misfortune that she had had a baby at all, considering the condition of her heart. I examined the front of her chest, but found no indication of congestion. I did not attempt to examine the bases, because of its requiring turning the patient over, which would be exhausting to her. I can quite believe that there w 7 as congestion of the bases secondary to the condition of the heart. I was told she had come out of St. Helens recently. I do not remember that I was told it was the previous day. The condition I found her in might come on very suddenly, and I cannot form any opinion as to how she might have been on the previous day, Gross-examined by Mr. Stevenson.] I did not express any opinion on the day I saw 7 your wife that it was a case of double pneumonia. My attention was directed chiefly towards your wife's heart, and I do not remember saying anything about her lungs. Cross-examined by Mrs. Nicol.] I first heard of Mrs. Stevenson's case in connection with this inquiry when I saw 7it in the newspapers. I have not discussed this case at all with Dr. Inglis. I would say that a baby of 6f lb. is one of a good average weight. I consider a gain of fib. in a fortnight quite satisfactory. I would be quite satisfied with less. Gross-examined by Mr. Mays.] I see Mrs. Stevenson's maternity chart. I should say it was quite normal. I see Mrs. Stevenson's General Hospital chart. The diagnosis at the General Hospital is quite in accordance with what I would expect. The disease of pulmonary embolism gives no warning of an attack. It is very very sudden. It is quite possible that death might ensue within a minute or two of an attack. Looking at the maternity chart, and knowing what I do of the case, I do not think it would have made any difference if Mrs. Stevenson had remained at St. Helens for another day. In maternity cases one may get embolism about the tenth day wffien the patient is first allowed up or as long as five or six weeks after. A case of multiple pulmonary embolism is not rare in cases of this kind—that is, in the case of a patient who has suffered from rheumatic fever. Had the officials known of the heart trouble following the rheumatic fever I know of no special treatment that could have been administered to guard against embolism apart from rest and care. St. Helens' nurses have been employed by patients of mine. I have experience of pupil nurses from there and certificated midwives who have been trained there. I consider that the training they get there is good and thorough. Cross-examined by Mrs. Nicol.] I was confused at first bj 7 the General Hospital charts. I understand them now. I find that one is a four-hourly chart and the other a morning and evening chart [Mr. Stevenson states that he is satisfied that his complaint has been thoroughly investigated, and, subject to the receipt of the statement from Mrs. Poole, he says that he has no further evidence to offer.] [Note. —Mr. Stevenson did not send in Mrs. Poole's statement, although he was requested to do so by the Commissioner.] Hester Maclean (called by Mr. Mays), on her oath, saith. I am Assistant Inspector of Hospitals. I was appointed on the Ist November, 1906, by Cabinet, under the Hospitals Act. That Act applies to this institution. I was informed when I took up my position that the inspection of and control of St. Helens Hospitals was particularly under nry charge. I am a certificated nurse, trained in the Royal Prince Albert Hospital, Sydney. I am registered in New Zealand. I am a registered midwife of the Central Midwdves Board of London, and I have a certificate from the London Obstetrical Society. St. Helens Hospital in Auckland was opened in June, 1906. I have inspected it at irregular intervals. My inspections have frequently been surprise inspections. St. Helens, Auckland, is staffed the same as the other three St. Helens, with the exception that at Wellington and Dunedin, where there have recently been additions to the staff. Recommendations have been made for some time for additions to the staffs at Auckland and Christchurch. It has been in contemplation for some time, owing to the increase of in-patients and out-patients, to add a third trained nurse to the staff. The number of pupils in all the St. Helens Hospitals has-been increased in accordance w 7 ith the increase of patients. Applications from pupils and trained nurses are frequently held over for a year or more while w 7 e are waiting for vacancies. I consider the curriculum prescribed by the regulations and the training both inside and out quite satisfactory. The teaching prescribed is the minimum necessary, but both in the practical training and the lectures more training is given than is actually required. The training in New Zealand is much on the same par as that in Australia, with the exception of Western Australia, where it is far above that expected in England. I know 7of no other hospitals established on quite the same lines as the St. Helens Hospitals. The number of complaints made by patients or their friends is very small. On investigation, I cannot say that there has ever been any serious cause for complaint. When the Hospital was established here the building was looked upon as quite large enough for the number of patients who w 7 ould avail themselves of it. The site was selected for the convenience of the women likely.to patronize it and for the convenience of the work in outside cases. It was seen in 1908 and 1909 that it would be necessary to have more accommodation. In view of the large number of patients attending, it was seen that there would have to be more regular hospital appliances. At times the home has been pressed to its utmost capacity, so much so that when patients in some cases who have booked beds have arrived there has been no room, and arrangements have had to be made with private hospitals. To my knowledge, the Department has never failed to make provision for any patient who has booked at any of the homes. Patients who have booked beds and have at the last moment been unable to come have always had their deposit fee returned to them. When patients who have booked arrive, and there is found to be no room, the Matrons have orders to ring up private hospitals and send them there, the extra fee being guaranteed to the private hospitals by the Department.

H.— 31b.

76

[H. MACLEAN.

To the Commissioner.] There is no understanding at the time of booking that the patient may be sent to a private hospital instead. When a patient books she is entitled to be taken in when her time arrives, provided there is room. It is not clearly stated at the time of booking that there is a risk of not being taken in. To leave them in a state of doubt would do a lot of harm. I think that no house originally built for a private residence is really suitable for a maternity hospital. Ido not think that the life of any patient has been endangered or sacrificed by any fault or defect in the home at Auckland, The home is not large enough for present or future requirements. The results obtained in the home here compare very favourably with the results obtained in the other three institutions in New Zealand, At Wellington we have a new and satisfactorj 7 home and a nurses' home as well. At Dunedin the house has been altered, and is fairly satisfactory, though the site is not so satisfactory from the point of outdoor work for the nurses. From all points of view, the site here is satisfactory. It is high, dry, and is not shut in. A drawback is being, on the tram-line, but that is compensated for by the fact that the patients step right from the tram into the gate. The site is very good for out-district work. It has a large population in its near neighbourhood, and is near the trams. I know of no better site available at a reasonable cost. Five years ago the Department began to think of a new building and to look for a new site. We would like more ground at the present site. We have had to limit the distance to which our nurses in outdoor work can go, practically to the penny-tram radius. In some instances this has caused apparent hardship. We have taken special cases under this heading into consideration. As to limiting the distance, it is necessary that the woman's husband should be able to get to the home and the nurse to the confinement before the baby is born. It was recommended several years ago that cottages be established in the suburbs to get over this difficulty. Adjourned to 10th February, at Arbitration Court. Monday, 10th February, 1913. Henry Schofield (called by Mrs. Nicol), on his oath, saith. 1 am Chairman of the Hospital and Charitable Aid Board in Auckland, under the Act of 1909. St. Helens Hospital in Auckland is in no w 7 ay under the control or jurisdiction of my Board. We have nothing whatever to do with its administration. It is a separate and distinct State institution. Nurses' report-books are kept in the General Hospital. These are kept in the Matron's room. They are the property of the Board. It is not a fact, to my knowledge, that the nurses' report-books are destroyed at the General Hospital. No records are destroyed there, to my knowdedge. Records ma} 7 only be destroyed under the authority of the Board. Certain documents have been destroyed, but these have been of a private character. The nurses' report-books are not destroyed. The house manager, Captain Thomas, is custodian of the charts at the Hospital. The Medical Superintendent can ask for a chart at am 7 time. I think Nurse Boyd left the Hospital to take up training at St. Helens Home. After that she resigned from the General Hospital She was appointed Matron at a hospital at Bay of Islands. Cross-examined by Mr. Mays.] I could not say if the nurses' day and night books are kept at the General Hospital for a longer period than two years. To the Commissioner.] I am not aware that there is any regulation of the Board or anything in the Act permitting the destruction of records. The history of all cases-treated at the Auckland Hospital is kept for a long time. We can go back for twenty years or more if necessary. Hester Maclean, cross-examination-in-chief continued. I know the report written by Dr. Valintine on Mrs. Chamberlain's case, which w 7 as sent on to the Minister and then given to Mr. Bradney, and which has been produced here. I know what gave rise to that report. It was a letter from Mrs. Nicol dated the 23rd September, and another dated the 12th September, to Mr. Bradney, M.P. Those produced are the letters to which I refer. [Exhibits Nos. 44 and 45.] They were sent to the Inspector-General on the 3rd October for urgent report by the Minister. They were referred to me, and I supplied the information, which we were already in possession of. I w 7 rote part of the report. My information was gathered from letters I had received from the Matron, Miss Ludwig, and also from my knowledge of the working of the institution. Monthly reports are sent in to the Department, and these are supplemented from time to time by semi-official reports of anything out of the ordinary that arises. [Mrs. Nicol objects to her letters being put in, on the ground of privilege. Letters admitted and read.] An annual report giving details of all cases admitted of any special features of cases and results are forwarded by the Medical Officer of each institution on a printed form. These are included in the annual report of the Department, These reports are based on the whole of the records kept in the hospitals. The report is on the model of that used at the Rotunda Hospital, Dublin. 1 produce three-monthly reports of St. Helens, Auckland, for the last completed year. [Exhibit No. 15.] The statistical report embraces four years. The monthly report for August and September last is in Wellington. All the pupil nurses enter in the pupil nurses' note-book all that they do by day and night. It is called a report-book, and is similar to that already produced. This is revised frequently by the Matron or submatron. When a case is completed the pupil nurse who has had chief charge of it writes all the notes in regard to the case on a separate sheet of paper, wffiich is then gone over by the Matron or submatron to see if it is correct. The paper is then placed with the chart and historysheet of the patient until the Matron has entered up the case in the Department case-book. The Matron does not enter (■very detail. One side of the book is provided for the history of the case, the other side for notes of the case. All the points of importance from the nurses' notes are put in the book under this note. When the ordinary night and day book is finished,

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and all the details taken out of it, a fresh one is issued, and the old one, being then of no value for the work of the institution, is destroyed. I produce an original extract from the nurses' day and night book. It is kept by the pupil nurse who lias been given charge of the case. It forms the foundation for entry in the case-book. The reason the pupil nurses keep these records is for their instruction, but they are carefully supervised by the Matron and submatron —that is, it is the duty of the Matron and submatron to carefully supervise them. The Matron or submatron verify the entries. In my opinion, the nurses' day and night books, and the sheets prepared by them, are of no value in the work of the institution subsequently. The present inquiry is the first of a formal nature that has been held. We never contemplated keeping records for other uses than the work of the home. Given plenty of room, there is no objection to keeping the records, though they will never be looked at again. We have all the material necessary for statistics in our monthly reports and the temperaturecharts. The latter are kept for a year. It has been left to the discretion of the individual Matrons as to what reports or records they will destroy as useless* That does not include casebooks and charts. The case-books must be kept. So far as the home is concerned, we regard the case-book as quite sufficient for all purposes. For the perpetuation of evidence and the preservation of it, it would be better to keep all the record of whatever kind, but for the working of the institution the case-books are sufficient. The legal aspect of the matter has never been raised since the hospitals were founded. There is nothing so far as the working of the institution is concerned to necessitate the keeping of records which we have already got in another form. I know the labour-bed to which reference has been made. There are more elaborate labour-beds than this, but this one has been found satisfactory by the Medical Officer when he has been required to attend a case, and it is as comfortable as can be compatible with safety in case of anything going wrong. Labour-beds are always made as firm and hard as possible. At the Women's Hospital, Melbourne, the mattresses were stuffed with straw as hard and firm as possible. The table in the bathroom is for the purpose of examining the women —to see how far the labour has advanced, and to see if there is time for her to have a bath before being transferred to the labour-room. There is always some place in other hospitals where the patients can be examined preliminarily. Women frequently cannot be taken as far as the proper labour-bed. Children have very often been born in the cab coming up. To admit patients before the commencement of labour would be the means of keeping beds for some time from those really in need of them, as time of labour cannot be definitely fixed, in some case's within weeks or even months. If there are any indications of anything that will complicate the case patients are taken in some time before their confinement is due. If the Medical Officer gives a certificate that any woman ought to be admitted for nursing and treatment before the time fixed in the rules the patient will be so admitted. Pupils and nurses are admitted for training in order of application, except that in special cases applicants are admitted earlier. Thus, exception would be made in the case of widows with families to maintain. Preference is also given to women from the backblocks who intend to go there after they are trained, and who enter into an agreement to go there after their training is complete, and also to those recommended by the Hospital Boards for free training and who are afterwards to work in country districts. St. Helens Hospital is known to be a training-school. It w*as established as much for the purpose of training midwives as for the confinement of the wives of working-men. Under the Midwives Act it was necessary for a pupil nurse to attend twenty women in confinement. This is the rule in all maternity hospitals. Pupil nurses are allowed to deliver women in the State maternity hospitals and outside too. They must be under supervision b}' the Matron or submatron, who is responsible. The submatron 'or matron must be present during delivery. The submatron undertakes the outside cases. Except in cases of emergency, no pupil nurse may deliver a woman outside the hospital except under the supervision of the submatron. Women make application to be attended in their own homes. They must sign the same application form and answer the same questions as to their means as those for inside treatment. Patients who in the judgment of the Matron are able to pay for private attendance are not booked. Assuming that the submatron is attending an outside case at one end of the town, and at the time word comes that a patient in another part is in labour, a senior pupil—one who is to be trusted —is sent along , to the latter case. If things are going all right she goes on with the case till the submatron arrives. If things are not going well she communicates at once with the Matron, who would either send for our own doctor, or, if he was not available, some other practitioner. The submatron goes whenever she is available. It is very seldom that there are two cases at exactly the same time. Outside cases have to book, though they often come at the last moment without having booked. They have to pay £1. This may be paid in small instalments. [Mr. Skelton does not cross-examine.] Gross-examined by Mrs. Nicol.~\ I am certificated by the London Obstetrical Society and registered by the Central Midwives Board. The London Obstetrical Society is not, T believe, now in existence. When the Act for the registration of midwives was passed the work of the society merged in that of the Midwives Board. I think the first examination under the Central Midwives Board was held in 1905. Ido not know that the Central Midwives Board had to come forward to inquire into irregularities of the Obstetrical Society. My training was a district training. My certificate was not one of service. I had to pass an examination. I was one of the first registrations under the Central Midwives Board. I did not apply to the Central Midwives Board to be recognized by them so as to be competent to teach. They did not refuse me. I came to Auckland in July, 1912, to look at a house which we thought of taking over for the St. Helens nurses. My visit had nothing to do with any move for an inquiry by the Waterside Workers' Union. I did not come up with regard to the case of Mrs. Reid. I happened to be here at that time. Mrs. Reid, I believe, lived outside the radius which the Matron thought it safe to book outside cases for. The circumstances were represented to the Department, and the Minister directed that special efforts be made to attend the case. I was in the

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[H. MACLEAN.

office when Mrs. Grace Neil was there. I was not there when a request from you went down during her time for an inquiry into St. Helens. I never saw a letter from the midwives asking that the extra fee be paid on account of women whom we were unable to accommodate, and wffio were sent to private maternity homes. Vouchers are sent on bv 7 the Matron, signed by the patient in question, and passed for payment. The amount is generally £2 to £3. 1 edit a paper called Kai Tiaki, issued quarterly. The subscriptions go into the pocket of the printer. They are not issued at 3d. per copy. If the paper gives a different date for the caesarian section performed by Dr. Inglis to that given by Dr. Inglis I say it is an error. 1 made a mistake which can be corrected in the next issue. I have never said that the site of St. Helens is not good enough. The untrained midwives who were granted a certificate are suspended for a month after they have attended a septic case. I know nothing about the wages of managers in the Kauri Timber Company. We may have been deceived by people making false statements as to their means. A large amount of our work is clone by nurses attending with outside doctors. I made a statement to a Star reporter who came to see me in Auckland in July last. It was in regard to the distance a nurse w 7 ould go to an outside case. I probably stated that the Cabinet had recently raised the income-limit to £4 per week. If the Star refers to £3 lam not responsible. Three pounds had been the rule for years. There has been no hard-and-fast rule as to income. Circumstances are considered. Ihere is a Cabinet minute to the effect that the rule limiting the income to £3 per week should be amended, making it £4 per week. At the present time if a man's income exceeds £4 per week his wife is not eligible for treatment. The woman has to sign a declaration as to the amount of her husband's income. It is provided on the form of application. It is only a statement and not a statutory declaration. The £3 limit extended from the establishment of the hospitals to June of last year, I think the fees were remitted in the case of Mrs. Hayes. To the Commissioner.] The £4-per-week limit applies to outside as well as to inside patients. Preference is given to those in receipt of smaller wages. Thus the wife of a man with £2 per week has a better chance than the roan w 7 ith £3 or £4 per week, because our Hospital is not large enough to take in all. We can accommodate eleven without overcrowding. We have arranged to lease a house for nurses. This will permit us to take four more patients without overcrowding. During my term of office very few have been sent away; I could not think of more than twenty altogether. To' Mrs. Nicol.] There is no rule that those coming from congested areas have a prior right over those coining from other districts. We do not take in unmarried women so far as we know. There is no rule as to unmarried women going to private maternity hospitals. No books that are looked upon by the Department as record-books have been destroyed. The Matron had no authority from me to destroy books. To the Commissioner.] The monthly reports containing Mrs. Chamberlain's case can be obtained. Re-examined by Mr. Mays.] The cutting from the Star [produced] is the one to which Mrs. Nicol refers. [Exfiibit No. 26.] I noticed afterwards the mistake of the reporter therein. I produce Mrs. Nicol's letter challenging my right to interview the Press. [Exhibit No. 27.] To Mrs. Nicol.] Ido not think notice was sent to me that Mrs. Porch w 7 as suffering from sepsis. [Letter from Mr. Bradney to Mrs. Nicol, dated the 28th October, 1912, put in by Mrs. Nicol. (Exhibit No. 25.)] To the Commissioner.] There is no set or regular time for inspection of the home. I do it three or four times a year. In addition, Dr. Valintine makes visits. As to outside patients, there is no limit of distance—it is rather one of accessibility. The principle is the ready accessibility to the nurse when called. The Matron decides every case on its merits. First confinements are not usually taken as outside cases. Circumstances vary so greatly that the Matron is not guided in her discretion by rules. She has an undoubted discretion as to any outside case. As to inside cases, the Matron has a discretion as to the family of the proposed patient, the suitability of her ow 7 n home, and as to whether the patient has already engaged a doctor or nurse. If the Matron refuses a case there is no appeal except to the Department in Wellington. There is no regulation with regard to the fees of midwives practising privately. Every patient is not examined by the Medical Officer before discharge. With the Medical Officer's permission given generally, the Matron is allowed to let patients go before the end of the usual time if their state warrants it. The matter of disinfection is left in the Matron's hands. It is left to the Matron's discretion, there being no rule on the subject. Sometimes the Health Department assists in disinfecting and fumigating. As it is part of the training of the pupils it is done most frequently by the officers of the home. There is nothing in the Act to compel the Health Department to do the disinfecting or fumigating. I do not know how the examiners of pupil nurses in Auckland were appointed. They were appointed before my time. Those in Auckland are Drs. Lindsay, Bull, and Robertson. No statutory time for examination is fixed. They are held twice a year —in June and December. One or other of the examiners prepares the examina-tion-papers. The questions are printed, and there is a practical and an oral examination as well. A book is kept in which the date of a lecture and the name of the lecturer is given. The attendance of a nurse is noted on her own record. There is no statutory declaration by an intending candidate that she has complied with the requirements of the statutes. She makes an application wffiich is accompanied by a certificate from the Medical Officer. There is nothing in the contract with an intending patient that the Matron shall be at liberty to send the patient, if the home is full, to a private home. Intending patients are informed that they will not be admitted till labour has begun under ordinary circumstances. If, wffien a patient comes to book, the Matron thinks there is anything about the patient demanding attention she advises her to go and see her own medical adviser or the Medical Officer of the home. If when a patient came

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she looked ill the Matron would take her in and get the Medical Officer to see her. If a patient brought a certificate from her own medical adviser that she required treatment she would not be taken in, unless the matter was urgent, without confirmation of our own Medical Officer. If a patient brings a certificate from our own Medical Officer the patient would always be taken in. Pupil nurses do not go out with the Medical Officer to attend his private confinements. They would not be taken unless they were going to do some of the work. They would not be taken just to look on Pupil nurses produce a certificate from their own Medical Officer before they are taken on. There is a period of probation for pupils. The nurses are not admitted even on probation without producing a certificate of physical fitness. When the Medical Officer wants further medical aid he himself nominates the medical man that shall be called in. Sometimes a doctor bringing in a bad case remains to assist. We frequently have more than one outside doctor in in the one case. In the case of a consultation being required the patient could not nominate her own medical man, though she could mention him, and her wishes would no doubt be consulted. The Medical Officer is not bound to consult with the man nominated by the patient. In anything in connection with the treatment of the patient the doctor w 7 ould rule over the Matron. We have never had the case arise. 1 am an Inspector under the Hospital and Charitable Aid Act. I was also appointed as Assistant to the Inspector-General. Martha Broadley (recalled by Mr. Skelton), saith. Mrs. Burns is our permanent laundress. She was away on sick-leave. I have forgotten the time. I cannot say if it was in June, July, or August, 1912. I do not know what was wrong with Mrs. Burns further than that she had a bad hand. Cross-examined by Mrs. Nicol.] Every night the labour-room is washed out w 7 ith disinfectant by the junior night-nurse. After each confinement the bed is washed over w 7 ith disinfectant, and clean linen put on. After about six or seven confinements the labour-room is fumigated. The patient is given a list of everything she requires when she books. We have a jar of sterilized swabs, sterilized towels, sterilized nail-brush, carbolic and monkey brand soap, boracic lotion for the baby's eyes, sterilized ligatures for the cord, bucket of Jeyes fluid for the soiled clothes, basins and disinfectants for scrubbing the hands in, clean overalls, plenty of lysol, plenty of sterilized water —hot and cold. Thomas Harcourt Ambrose Valintine (called by Mr. Mays), on his oath, saith. I am Inspector-General of Hospitals under the Hospital and Charitable Institutions Act, and have been such since 1907, and Chief Health Officer since 1909. I am Registrar under the Midwives Act, 1908, and also under the Nurses Registration Act, 1908. My position with regard to St. Helens is shown under section 5 of the regulations under the Midwives Act. The only regulations that have been made and gazetted under section 19 of the Midwives Act are those in Gazette, of 27th April, 1905, page 1022. On receiving my appointment I was told that I was to carry out the duties performed by my predecessor. Miss Maclean's particular branch is the oversight of St. Helens homes. She is also largely responsible for matters affecting the registration of nurses and midwives. She is also Assistant Inspector of Hospitals The Rules for the Management of the State Maternity Hospitals are merely rules. They were made by the Department —that is, by Miss Maclean and myself. They are made under the Act. They are not gazetted. They are not made by Order in Council. They are subordinate to the gazetted rules. They have not the authority of the Minister. They were referred to the Minister and approved by him. I am distinctly under that impression. They were made in 1911. The rules made in 1905 are not in force. They were merged in those of 1911. The Department issues extracts from the rules in leafllet for [produced], [Exhibit No. 66.] Miss Maclean and myself drew up the Rules for the Guidance of Midwives. They have not been gazetted. They are distributed to pupil midwives and registered midwives. I think I may say that I have been associated with the State maternity hospitals practically from their formation. In setting them up and carrying them on we have not have the advantage of precedent from any other country. The work is such that it goes a good deal, further than that of maternity hospitals of the United Kingdom and other countries that I know of. I know 7of no such institutions in other countries where they are administered entirely by the State. St. Helens Home in Auckland was opened in June, 1906. Those in Wellington, Christchurch, and Dunedin were opened in succeeding years. On the sth August, 1912, I reported to the Minister on the whole of St. Helens Hospitals and other matters relating to the Midwives Act. [Exhibit No. 46.] I may have discussed the matter with the Minister on the 12th August. The report was instigated by an attack on the St. Helens Home in Wellington by the British Medical Association, and by a letter received from one Mrs. Emily Nicol, of Auckland. I gave the Minister a general report. He asked me to report on the letters, and I took the opportunity of making a general report on the whole matter. Speaking generally of the institutions, they have most decidedly carried out their original purpose. Some 7,000 cases have been treated and some 250 midwives have been trained in them. Auckland St. Helens Home has most certainly been, up to the standard we require. It has been an excellently conducted institution. All the four St. Helens homes are alike in the system of management.' The books required to be kept in every St. Helens Home are twenty-one in number. Those are to be kept by the Matron. She has also to fill in numerous returns. 1 produce a list of the books kept. [Exhibit No. 29.] The books are excellently kept. In very few 7 hospitals are the books better kept, and in none is the data required more immediately available. I cannot give a list of the books that have been destroyed. No case-books have been destroyed. The rough drafts from

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which they are made up have been destroyed. Matrons at St. Helens are in a different position from General Hospital Matrons. They have no Resident Medical Officer, they have no clerk, and they have to do administrative work and actual nursing. I agree that,'under the circumstances, it would have been better had what I call the rough notes been kept. No instructions have been issued to Matrons as to the destruction of documents which the Matron here failed to keep. Each Matron has been left to act according to her own views and as to her previous training as to what was necessary to keep. A Matron's principal duty is, of course, to look after the sick —that in a general hospital may be summed up as " supervision." Besides looking after the sick, a Matron is responsible for looking after the actual nursing. She has also to teach the nurses their duties. She has to supervise, besides the nursing staff, the domestic staff; she also has in many hospitals to undertake the housekeeping, and to do a considerable amount of secretarial work. Those are the duties of a Matron in a general hospital. As regards St. Helens, the Matron is also responsible for an increased amount of secretarial work and tht actual nursing of the sick —that is, she has to be a midwife as well. In the St. Helens homes in New Zealand there have been 6,240 cases treated, with twenty-two deaths, being a-mortality of 034 per cent. In the preaseptic days the rate of maternity hospitals was from 2 to 3 per cent. Now it varies from o*s to 1 per cent. Last year the mortality rate of our St. Helens Hospitals was 0' 14. I submit these statistics with a good deal of pride, because I believe they are the lowest on record of all hospitals. As to the morbidity rate —that is, the record of all rises of temperature —it averages 8"7 per cent. For the same period Auckland was 67. Comparing these with records shown in Edgar's " Book on Midwifery and Practice of Midwifery," pages 945, 952, shows greatly in favour of St. Helens. [Records showing rises of temperatures maintained over two days during four years from 1908 to 1912 put in and verified by witness.] [Exhibit No. 60.] There have been twelve septic cases in Auckland from the beginning — i.e., 1906. I produce a list showing those who suffered from it. [Exhibit No. 61.] There has been a very great diminution in the mortality rate of infants during the last ten years, but I would not go so far as to say that the influence of St. Helens has been entirely responsible for this extraordinary diminution in the rate. The mortality rate per 1,000 births of infants last year was 56 for the Dominion; in 1902 it was 82. Auckland last year, 63; in 1902, 140. Wellington, 73; 1902, 130. Christchurch, 62; 1902, 117. Dunedin,' 43; in 1902, 89. It is very fair to assume that institutions like Plunket Nurses and St. Helens have had a very potent influence in the diminution of the rate. I have not considered the question of the appointment of a Resident Medical Officer for St. Helens. The suggestion is too absurd. It is very much better to have a general practitioner in actual practice who can show the nurses what will be expected of them in private homes than an officer who devotes his time entirely to institutional work. Moreover, what hospital in the world would be justified in having a resident for an institution of twelve beds. I say, undoubtedly, that a practitioner with a large practice can find sufficient time to attend to this home. 1 am absolutely opposed to these institutions being under the control of the Hospital Boards. I certainly think they are better managed as they are. There is nothing to prevent the hospitals establishing a maternity ward if they wish to do so. We have had protests from different labour organizations against the institutions passing to the control of the Hospital Boards. There is, too, a desire to keep out any suggestion of charity. If the institutions were made charities a certain stigma would undoubtedly attach to those born in them. I certainly think single women should not be treated in these institutions. There is ample provision for them. Do what you will you will not get a single woman to go to a recognized maternity home if she can possibly avoid it. The Governor has not appointed examiners under section 18 of the Act. Dates of examination have been fixed—June and December. Examiners have been appointed. [Mr. Mays contends that the question of the appointment of examiners under the Act is not a matter which can be gone into under this Commission. Mr. Mays further requests that if the Commissioner does inquire into the matter of the appointment of the examiners that he send in a separate report on the subject. Commissioner rules that he can go into the matter, and decides that he will consider as to making a separate part of his report on the subject.] I appoint the examiners. They are not gazetted. Examiners were appointed by my predecessor. I found that had been the custom. So far as Auckland is concerned, the same examiners have been continued in office up to date. The utmost that an examiner has got is about £6 per annum. As to the report made by me which has been put in, I produce the letter to the Minister, which covered it; it is dated 3rd October, 1912. [Exhibit No. 56.] I produce the correspondence between Mrs. Niool and the Minister. Letter 23rd July, 1912, Dickson, M.P., to Hon. Mr. Rhodes, enclosing a letter received by him from Auckland Waterside Workers (in Mrs. Nicol's handwriting), dated 16th July, 1912 [Exhibits Noa. 43 and 42]; letter dated 2nd September, 1906, from Mrs. Niool to Minister in Charge of Hospitals [Exhibit No. 39]; letter dated 16th July, in Mrs. Nicol's handwriting, from Auckland Waterside Workers' Union to the Premier [Exhibit' No. 40]; letter dated 6th August, 1912, from Mrs. Nicol to the Minister in Chaige of Hospitals [Exhibit No. 41]; letter dated 17th August, from Mrs. Nicol to the Minister in Charge of Hospitals [Exhibit No. 37]; letter dated 17th August, 1912, from Mrs. Nicol to Hon. Minister [Exhibit No. 38]. [There are other letters from Mrs. Nicol, which Mr. Mays does not think should go in, as they are, he states, not relevant.] Cross-examined by Mr. Skelton.] I remember my report quite well. It was made up from notes prepared for my signature by Miss Maclean, except the last paragraph. The Matron was the source of Miss Maclean's information. At the time of the report I did not know that in Mrs. Chamberlain's case there had been a rupture of the perinseum with two sutures. From the letter to which I was replying I thought that the operation referred to was one of laperotomy —that is, the opening-up of the abdomen. That is, of course, a surgical operation, Adjourned to I.lth February, at 10 a.m.

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Tuesday, 11th February, 1913. Ebenezer Joseph Thomas (recalled by Mr. Skelton), saith. 1 produce the book of the Auckland Hospital, relative to the treatment of a certain Mrs. Burns last year at Auckland Hospital. It is the Outdoor Patient Book. The date of the patient being first treated is the 2nd September, 1912. The entry is as follows: " 2nd/9/12. — Mrs. Burns, St. Helens. Nature of injury: Hand Biliod comp. Dated admitted, 2nd/9/12. Dressed by Dr. Ardagh." The patient was under treatment off and on till the 4th October, 1912." Gross-examined by Mr. Mays.] The book does not show when the patient's hand was opened by the doctor. The nurses' da} 7 and night reports do not come into my hands. All permanent records are handed to me. Ido not know what becomes of the nurses' day and night records. Thomas Harcourt Ambrose Valintine, continued. To the Commissioner .] The Matron was transferred from the Christchurch St. Helens Hospital, where she was acting Matron. She was appointed by Mr. Fowlds. There was no appointment by the Governor. There w 7 as no Cabinet minute. The appointment was made by the Minister without the Governor's warrant and without a Cabinet minute. The submatron was appointed in the same way. There is nothing in the Act with regard to submatrons. [Mrs. Nicol declines to go on without the ruling of the Commissioner as to her right to see the whole of the entries in the three case-books of the institution which have already been put in in connection w 7 ith this inquiry. Mr. Skelton claims the same right, and, in addition, the right to inspect the temperature-charts which have been, put in unopened. Mrs. Nicol wishes further to inspect the Tndoor Admission Book. Mr. Mays states there is no objection to the inspection of the Indoor Admission Book. Mrs. Nicol states that the name of Mrs. Lynch, who was confined in the home on the 24th May, 1912, does not appear in the book. Mr. Mays shows an entry relating to Mrs. Lynch admitted on the 4th May, and discharged on the 15th May, 1912. Question of inspecting the books, &c., to stand over in the meantime in order that the desirability of stating a case for the opinion of the Supreme Court may be considered. Mr. Skelton and Mrs. Nicol both request that a case be stated under section 10 of the Commissions of Inquiry Act, 1908.] Crossf-examined by Mrs. Nicol? Whether a physician or a surgeon would be better as a Medical Officer depends upon the man. A nhvsician would not necessarily be the better of the two. A surgeon is specially trained in asceptic matters. Physicians often attend maternity cases in the Auckland hospitals, and such cases are very often transferred to the surgical side — it depends on the case. Tn the general hospitals the nhvsicians, as a rule, attend the maternity cases. T do not consider it necessary to depute a physician to attend the cases at St. Helens. 7 consider that a surgeon, notwithstanding that he may have to attend many dirty cases, is quite suitable for the position of medical officer in a maternity hospital. Su'-o-pons are sneciallv trained in asoentic methods. Dr. Tnsrlis takes clean surgical cases at the Auckland Hosm'tal as well as sentic surgical cases. There is no danger whatever in the ease of a medieril officer of Dr. Inglis's experience, after attending dirty surgical cases, in attending nt St. Helens. He must fake proper precautions. That he does so is a matter for bis own notion*-. T atrree that sentic infection is a distinctly nreventible accident of parturition, but in the hosm'tal of Dr. Jellett, who is a recognized authority, and who is the author of the statement that sepsis is nreventible. sepsis is by no means unknown. I first had information r°gardine- Mrs. Chamber-lains-trouble on the sth September. T was informed by Dr. Tnedis or Dr. Goldstein of it. So far as I know. I had a telephone message from Dr. Inglis when T was in Auckland savins 7 that he had a case of doubtful sensis in the Hosnital. I was in Auckland at the time, to hold an inquiry into the Administration of the Auckland Hosnital. T did not state that it was your letters that caused me to inauire into Mrs. Chamberlain's case. WHien T cot the message from Dr. Tnglis T went round to St. Helens, T saw the Matron. T discussed the ouestion with the Matron. Mrs. Chamberlain was in the isolation ward at the time. We exnected Dr. Goldstein, but T did not see him there, thourrh I saw 7 him later the same day. T told the Matron to take all possible precautions, and not to adroit nnv more cases, but to make arrangements for their accommodation outside, T did not examine Mrs. Chamberlain, nor did I make an? investigation. It is not mv practice to interfere with the treatment of cases. T have a very vivid recollection of your letter to Mr. Bradnev. dated the 23rd September. My report w 7 as the result. Ido not know wffiv you were so lonff in fretting the renort. You asked me to come to your bedside at the Auckland Hospital on the 15th October. T went. You said to roe, "I am afraid I have been very bitter." This was the first time w 7 e had met, though we had been corresponding for a long time. I said, "We w 7 on't talk about that. You are ill now 7 ." Then we had some conversation about a consumptive case, but it w 7 as a very rambling statement, and Mrs. Nicol being very ill I got away as soon as T civil.lv could. That is all that took place. I did not see Mrs. Nicol again till this inquiry started. My report was founded on the reports of the Matron, summarized by Miss Maclean. I suppose the legal aspect of the home has never been raised, because there have been no inquiries. The legality of the home has never been questioned. You asked for a number of inquiries. None were aranted till the present one. Ido not remember Mrs. Grace Neil coming up and holding an inquiry, at wffiich you and Dr. Inglis w 7 ere present. T have heard about it. The fact is on the file of the Department. I remember you asking for an inquiry in 1908. It was not granted because the request was made on such futile grounds. The rule as to indigent patients does not require that the woman should go before the Hospital and Charitable Aid Board to ask for the application fee. When an -applicant asks for reduction or remission of fees the circumstances are gone into, and if it is considered right

11— H. 31b.

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[t. h. a. valintine-

a reduction or remission is made. It is generally done by the Office in Wellington, though some cases are referred to the Minister. The Matron has no power to deal with such applications. We have taken fees as low as half a crown —that is, as a deposit on the fee. The practice is for the Matron to forward to the Head Office any application for remission or reduction of the fees, and the Head Office decides. lam under the impression that the income-limit has always been £3 per week. It has been such since I have been in the Department. Last May it was raised to £4. There is a Cabinet minute on the matter of raising the limit of income. The limit by Cabinet was ,£2OO per year. I have wanted to build a new home at Auckland ever since I have had anything to do with the institution. I gave the reply to the question put in the House as to the death in the home from puerperal septicaemia, and as to the precautions taken to protect the other patients. At the time I wrote the report from the answer was given there had been no further cases of septicaemia since Mrs. Chamberlain's death. I know that the Matron after Mrs. Chamberlain's death refused to take in cases for a period. She was afterwards informed that she could commence again to take in cases. I was sure that all precautions had been taken to prevent spread of the disease. Mrs. Porch's case was the only one that occurred since. No cases admitted to the home developed sepsis after Mrs. Chamberlain's death. Mrs. Porch developed sepsis, but she was in the home at the time of Mrs. Chamberlain's death. There has been no trouble since. So far as I can remember, 1 did not know of Mrs. Porch's case when I made the report. I went through St. Helens on the sth September. Dr. Makgill was with me. The only case I saw, and that was just through the door, was Mrs. Chamberlain. I was on an official visit. I do not remember Mrs. Porch's case being mentioned to me. Had she been violently insane it does not necessarily follow that my attention would have been drawn to her. A swab would be taken to see if there was any sepsis. When I visited the home on the sth I was under the distinct impression that Mrs. Chamberlain's case was. the only one of sepsis then in the home. On the sth September, when at the home, I was not, so far as I can remember, told of Mrs. Porch's case. I knew of Mrs. Porch's case when I wrote the report, but at that time I did not regard it as a septic case. I had not the Matron's reports before me when I made up my report on the 4th October. The charts that go from St. Helens to the General Hospital are, I think, all numbered. There is no number on the chart relating to Mrs. Porch [" A," alreadj' produced]. There was no need of isolation after Mrs. Chamberlain's case. After due precautions the nurse could go on duty the next daj r . The period of isolation of outside midwives depends on the case and the report of the District Heath Officer. Those that cannot be kept under proper control are mostly isolated for a month. Provided every possible precaution is taken in an institution a nurse should be able to go on duty again in a few hours. Outside an institution the position is quite different. I do not know how Mrs. Porch developed her sepsis. If there is a boardinghouse which takes in St. Helens patients while waiting for their confinement that has nothing to do with the Department. I do not know such a place. I know nothing of the number of steps that patients have to go up and down in the boardinghouse. There is no relationship between St. Helens and any boardinghouse. I saw some of the evidence taken down at the meeting between you and the Minister. I certainly had a right to see it. I saw Chamberlain's statement, which was handed to the Minister. ["Documents connected with Mrs. Nicol's interview with the Minister in Auckland put in (Exhibit No. 54).] I certainly played no part in keeping you from getting the assistance of counsel. I told the Minister that I thought the idea of paying your counsel was absurd. My salary is £850 per annum, with travelling-expenses. Provision for unmarried mothers is made by St. Mary's Home, Otahuhu, and the Salvation Army Home, Auckland. I think it perfectly fair that a nurse going in for maternity training should pay £20 for her training. Tf she cannot afford to pay she can get a recommendation from the Hospital and Charitable Aid Board. A circular to this effect was sent out some time ago. A few have taken advantage of the training free, on condition that they went afterwards to the backblocks. I think the arrangements about the training nurses are excellent at St. Helens. Trained nurses and maternity nurses are quite different. The former requires more training. The nurses at St. Helens have do allotted hours. A nurse on day and night duty has the matter pretty much in her own hands. If she is not feeling up to it she can report it, and arrangements are made at once for her relief. A good Matron will find out the state of the nurse without the necessity of the nurse herself reporting that she is fagged. In some circumstances it might be very right, and in others it might be very wrong, to keep a nurse on duty with a dying patient for twenty-four hours. I think I retailed to the Minister the conversation you and I had in the Hospital. That was not in writing. I do not know that I told the Minister that you absolutely apologized to me, but I did say that you practically apologized. To the Commissioner.'] There is no actual regulation as to age-limit in connection with the age of pupil nurses. There is a note on the form of application that applicants must be over twenty-three and under forty. To Mrs. Nicol.~\ Tour many requests for inquiries have had absolutely nothing to do with the burning of the books at St. Helens. Re-examined by Mr. Mays.} I have had a considerable number of arguments with the British Medical Association. The British Medical Association does not always agree with the policy of the Department. Some of the members consider that the policy of the Department is detrimental to the interests of the profession. I would not countenance the trouble between the British Medical Association and other local practitioners if it in any way affected the administration of St. Helens Hospital. If Dr. Inglis is bound by any rule of the British Medical Association or similar body, and such is likely to interfere with his duty to St. Helens, I should expect him as an officer of the Department to follow out my instructions. Everything must be subordinate to the welfare of the institution. I am not a member of the British Medical Association, nor are any of my officers. We disassociate ourselves from the British Medical Association on account of the difficulty we are sometimes put in with regard to administrative matters.

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T. H. A. VALINTINE.

I have inquired into Mrs. Nicol's prior complaints, with the result that I found that they were all groundless. I know the course of training for the Central Midwives Board and the standard of their examinations. They have a three-months' training, whereas ours is twelve months for untrained women and six months for registered nurses. Charlotte Ellen Josephine Adams (called at request of Mrs. Nicol), on her oath, saith. To the Commissioner.] I am a general trained and certificated nurse from the Auckland Hospital. I was trained in the Auckland Hospital. My term of tuition was three years. I then passed my examination and got my certificate. That was in January, 1912. I was called in by Miss Ludwig to nurse Mrs. Chamberlain in the isolation ward at St. Helens. I nursed her for a week. I was there when she died and for a week before that. The baby was not there. My duty was to attend on Mrs. Chamberlain night and day for a week before she died. I think I got a little sleep during that time. After the death I stayed in the ward till the morning and then went to the nurses' club. I was thoroughly disinfected before I left the isolation ward. When I was sent for to go to St. Helens I was at the nurses' club, and was not then in employment. To Mr. Mays.] 1 do not remember if I was asked if I wanted assistance; I did not ask for any. In private practice it very often happens that a nurse has to do both day and night nursing. I did not think I was being overtaxed. I felt quite able to do the work without fatigue. I am sure I did full justice to my patient. I also nursed Mrs. Porch. 1 saw 7 the man commencing to dinsinfect the ward after Mrs. Chamberlain's death, I soaked the bedclothes and utensils in Jeyes fluid. The mattress was burnt. When I returned to the ward I could smell the fumigation—it was pretty strong. I was satisfied that the ward had been sufficiently disinfected. I nursed Mrs. Porch for a few 7 days. I had assistance with her. That w 7 as because she was a mental case. Cross-examined by Mr. Skelton.] Mrs. Chamberlain did not look very ill, and she did not complain of any pain. She had a slight cough sometimes at night. She w 7 as not delirious. I do not remember a bad smell about her. I do not remember if her stomach was distended. I remember telling Mr. Chamberlain not to stay any longer on the night his wife died. I do not remember telling him that night that his wife had blood-poisoning. I am almost sure I did not. I never gave him information at all. I remember no conversation to the effect that he had been informed that it w 7 as chest trouble and my saying that I could not really say what it was as I had never had it definitely from the doctors. I cannot say when I was first told it was a septic case. I was not told definitely that it was septicaemia when I first came. I kept a chart. Considering the treatment she was having and her temperature I thought she was suffering from septicaemia. I thought that from the start. Mrs. Chamberlain told me she had had stitches put in. She did not say how many. I did not examine her there. She said nothing about her confinement, I did not see the laundress, Mrs. Burns. I did notice a laundress there. Cross-examined by Mrs. Nicol.] Mrs. Chamberlain died late in the evening. Ido not remember the exact time. I laid her out by myself. I thought it was quite right—it was unavoidable —that I. should be left alone with Mrs. Chamberlain after she died. There is no bell to the main building. One night when I thought I w 7 ould want help a bell was fixed up. I had laid out a good many bodies prior to this. I was disinfected before I left the ward. I returned to duty between 9 and 10 next evening. I then took over Mrs. Porch, with the assistance of Miss Jakeman. The day-duty nurse slept in a bedroom off the isolation ward. I got much rest at that time. I slept very well. To the Commissioner.] I have no complaint to make as to my treatment when on duty with Mrs. Chamberlain and Mrs. Porch. I did not think that the task set me was more than I should have been asked to undertake. I never thought of it at all. The two cases were special cases. To Mrs. Nicol.] I put the hours of the patient sleeping down on the chart. I wake easily when the patient wakes. I remember Dr. Frost taking the blood-test. I remember some enamel dishes on the table. Mrs. Porch had milk, food —milk and water. She could not retain any other food. She vomited it, I try to keep my charts clean. Sometimes I blot or mismark them. Then I destroy them and write them out again. I do not remember if I dirtied Mrs. Porch's chart. I see my writing on Mrs. Chamberlain's chart. I commenced to keep it from the 3rd September. I took the temperature every six hours. The last of the charts and a portion of the second is in my writing. When Mr. Chamberlain came his wife had been dead a few minutes. Mrs. Porch was not unmanageable. Her treatment was different from that of Mrs. Chamberlain. I had the wdiole of the night on which I took up Mrs. Porch's case in bed. On the night of Mrs. Chamberlain's death I remained in the next room for the remainder of the night. Chamberlain said he was having his wife embalmed because he had to take her away into the country somewhere to be buried. Re-examined by Mr. Mays.] I told Mr. Chamberlain to remain near a telephone on the night his wife died. He said he would see some people on his way home, and ask them to take a message. He had given me two numbers earlier, and on the night his wife died I asked him again to be sure and give me a number which I could ring him up on. A case I have just come from, and which I had without assistance, was harder than Mrs. Chamberlain's in many ways. To Mrs. Nicol.] I cannot say who took my place when I left nursing Mrs. Porch. To the Commissioner.] Mrs. Chamberlain died about midnight on the 9th. I had made arrangements with Chamberlain the same night to ring him up. He left a number, but we could not get an answer when we rang. About three hours before his wife died I considered that the time had arrived for ringing him up. It would be earlier than 9 p.m. There is no telephone in the isolation ward. I sent a message to the Matron to ring up by one of the nurses who was passing the isolation ward. I gave her the number. [Mr. Skelton asks for leave to absent himself from the inquiry till Friday, 14th February, instant. Granted.!

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[C. LUDWIG.

Wednesday, 12th February, 1913. Mr. Skelton not present, Charlotta Ludwig, recalled, saith. To the Commissioner.] I see the form produced, " Further Notes, Treatment," &c. The details put in this form are written up from the nurses' report-books. It shows the treatment and condition of the patient from day to day. A similar form was filled up in the case of Mrs. Chamberlain. This form w 7 as torn up after 1 wrote it up in the case-book. The entries in the case-book are condensed. The form was torn up after Mrs. Chamberlain's death; it may have been two months after —1 could not be certain. I expect the nurse would have entered the prescriptions on Mrs. Chamberlain's form. The form is kept in conjunction with the tempera-ture-chart.. We keep the temperature-charts for a year, so that Dr. Inglis can make up the morbidity list, which he does at the end of each year —that is, 31st March. After Dr. Inglis has prepared his annual report I am allowed to tear up the charts. We have never kept a record of diet on the form. When there is a special diet the nurses make a note of it in the book. Mrs. Chamberlain's form has been destroyed, as has the nurses' report-book. It is not possible for me, or the doctor, or submatron to give a detailed account of Mrs. Chamberlain's case from her admission till her death except from memory. I cannot say definitely wffiat food the patient had from the 11th August to the 24th, or subsequently. As to medicine, I can only speak of the cough-mixture and the salol and boric. Dr. Inglis ordered this treatment up to the 24th, when the patient w 7 as isolated. Up to the time of isolation the patient had not been treated for septicaemia, I can only tell from memory wffiat treatment the patient had after isolation. I expect the prescriptions would have been entered on the chart which has been destroyed. I know that there were two prescriptions ordered —those already produced. The patient had hypodermic injections. I w 7 as not told the case was septic when she was isolated. I was only told that she was being isolated as a safeguard. It was about the end of the month that I w 7 as informed that the case was a septic one. Dr. Inglis told me he was reporting the case. That was about the end of the month. The entries in the case-book are not a copy from the chart. The case-book does not give the daily items, nor does it show the prescriptions given. The doctor can, if he wishes, enter on the chart the prescriptions and diet. The nurses could make the notes on the chart from day to day instead of entering them in the book. Ido not know why the doctor does not enter his instructions on the chart. Such has never been done in the chart. I have to trust to my memory as to the instructions as to diet and treatment. I always put it dow 7 n in the daily report-book after the doctor is gone. I report, a high temperature, and leave it to the Medical Officer to be responsible for the case after that. To Mr. Mays.] Mrs. Burns w 7 as the laundress. I remember her having a bad hand in August. She was taken off duty on account of her hand. The hand had not commenced to suppurate on the day she was taken off duty. It commenced to suppurate two days after she was taken off duty. It is quite impossible that the laundress's hand could have been the source of the sepsis in the Hospital. Nurses do sometimes get sore hands. When such occurs they are, immediately taken off duty. I produce the book, record of district nursing. To the Commissioner.] I have been nearly three years in St. Helens, Auckland. I think Mrs. Chamberlain's and Mrs. Porch's cases are the only cases of septicaemia that have occurred since I have been there. There have been none since. There have been several high temperatures, but not attributable to sepsis. I have examined the books of the institution right back to the beginning for the purpose of seeing how many cases of septicaemia there have been, I went through them carefully. The cases on the list already put in are the only ones I could discover. I believe it to be a complete list of septic cases. From September, 1909, Mrs. Chamberlain's and Mrs. Porch's are the only septic cases that have occurred as far as I know. I knowthat the return showing that there have been nine deaths in the home since its opening is true. I have ahvays found the time between July and November as most favourable for the production of sepsis. In my opinion, the Hospital has at times been overcrowded. I know we were busy in July, August, and September last year, but I could not say without looking up the books if we were overcrowded. We can only accommodate twelve pupil nurses. Eight of these reside inside and four outside. In addition, nvyself, the submatron, and cook, housemaid, and laundress sleep on the premises. Two of the nurses sleep in the isolation ward, one in each room. Four sleep in the large room near the front door. I say that the accommodation in the building for the nurses is not at all satisfactory. I sa}' it would be quite impossible in a hospital of this kind to fix maximum hours of w 7 ork for the nurses. We keep them to the eight-hour system if we can do so. I. try to manage so that only two off-duty nurses are kept in at a time. There are always three on duty and the two in reserve. The others then can get out. All the nurses go on duty at 6. All but three come off at 10. These three remain on till 2. Three more come on from 2 to 6 p.m. Then the others come on from 6 to 10. Occasionally wffien we are very busy the nurses are worked hard. I have no regular off-duty time at all. When I came here first I found the clerical work, of the institution too much, and help was given me, and it has been continued since, I have found the work rather much during the last year, and I have asked for help. I wanted another trained nurse, I applied, and was told I could have one in the Hospital as soon as there was accommodation. In the meantime I was to get outside assistance when required. I have not yet got the trained nurse. The work has increased so rapidly that an extra trained nurse is required inside. I certainly did not consider that Nurse Adams was overtaxed in her duties attending on Mrs. Chamberlain and Mrs. Porch. I think it would be unwise to put single women for confinement into the home witn the married women. Some of the married women certainly- would resent it. No applicant for admission has been refused without reference to me. When women ask for remission or reduction of fees I refer them to the Charitable Aid Board. All emergency cases are taken in if possible The Charitable Aid Board gets the patients in under reduced fees. The Board pays for them. I do not book patients without fee unless they come through the Charitable Aid Board or unless I have Miss Maclean's sanction. 1 think f should like clearer rules made as regards the booking.

G. LUDWIG.i

85

H.—3lb.

Emergency cases, too, provide a difficulty when the home is full. Two monthly returns put in as examples—August and September, 1912. [Exhibit No. 15.] Mr. Mays says that the complete correspondence between Miss Maclean and Miss Ludwig dealing with Mrs. Chamberlain's and Mrs. Porch's case has been produced.] I believe those already produced are all the letters that passed between me and Miss Maclean on the subject. The only objections I have to the present site are that there is a good deal of noise from trams, and traffic on the street, and dust. The country patients complain more of the noise than the town patients. Apart from this, the site, in my opinion, is an excelient one, being central and easily accessible to the districts which it principally serves. [Mrs. Nicol was not present during the examination of witness Miss Ludwig.] Robert Haldane Makgill (called by Mr. Mays), on his oath, saith. I am District Heath Officer at Auckland, and also Government Pathologist. 1 think the Medical Officer at St. Helens, in notifying to me cases of septicaemia, probably confines himself to the general septicaemia. There is a good deal of doubt as to the interpretation of the word " septicaemia," and various practitioners interpret it in different ways. It is obvious that every case of sepsis is not intended to be notified, otherwise every time a person had a boil it would have to be notified to the Department, A general septicaemia would mean where the blood is invaded by the organism, or where the person is so far poisoned by the products of the organism, as to be in a state comparable to a general infection. It is left to all medical practitioners to use their judgment as to whether or not tin particular case is one to be reported. There is no hard-and-fast line. There have been only four notifications of puerperal septicaemia from St. Helens since its foundation. The statistics of the home show 7 thirteen cases of sepsis. One case was reported on the 14th March, 1908; another on 19th March, 1908; the other two w 7 ere those of Mrs. Chamberlain and Mrs. Porch. r lhe date-stamp on the last two can, 1 think, be accepted as accurate. We are always ready to send tiie Inspector up to St. Helens to do the disinfection. The disinfection of private houses is done by the Hospital Board. Inspector Grieve went to the home on receipt of the notification relating to Mrs. Chamberlain. He reported to me on his return. I was quite satisfied as to the ability of St. Helens staff to carry out the disinfection and fumigation. It is the duty of the Inspector to see that the fumigation and disinfection is done and the right strengths of material used. I believe that the disinfection after Mrs. Porch's case w 7 as done by our own staff. Of this lam not quite sure. I know of Mrs. Chamberlain's case. I saw the patient on the sth September. I know also that Mrs. Chamberlain's child born at St. Helens died on Sunday last. Assuming that the child died of tubercular meningitis, that suggests that it received its infection from a maternal source —it dying so young. As to St. Helens Hospital, I think that we require a new home. At the same time, I am not aware of any patient who has been treated who has suffered in any way from the structural disabilities of the home. I have seen the statistics of the home. I have compared them with statistics from other countries. Those of St. Helens are extraordinarily favourable to New Zealand and to Auckland. I think it is a great feather in the cap of the staff that they have kept the mortality and sickness returns so low- considering that they are the people who have suffered from the fact that their work has to be clone in a building both old and unsuitable. As time goes on the risk of injury to patients from the structural defects of the building will not diminish. It will rather increase. Speaking from a bacteriological point of view, Mrs. Chamberlain's rise of temperature took place almost immediately after the birth. I conclude from that that the infection, whatever it might be, certainly did not arise at the time of labour. In the cases of rapid septic infection—that is to say. where the temperature rises within twenty-four hours of the time of infection—the organism is an extremely virulent one, and such cases are generally rapidly fatal with extreme rises of temperature. The impression I formed w 7 as that the infection was not a streptococcal one. The finding of the streptococcus later on in the case had not, to my mind, a vei y special significance. Its presence in the uterus might not argue more than that it had found lodgment in an already weakened organism, and that it was leading a saprophysic existence—that is, that it was merely a parasite, and not producing any symptoms. It certainly did not- prove that the case was one of streptococcal infection. I agree with the statement from Williams, 1908 edition, page 878. Tracy Russell Inglis (recalled by Mr. Mays), saith. I produce the complete returns, as required by the Commissioner, of indoor and outdoor patients treated since the beginning of the institution (1906) and up to 6th February instant. [Exhibit No. 61.] According to the books, 1,421 women were treated in the home since its foundation. Of these, nine died. Seventeen infants died in the home during that period. The number of still-births is incomplete; that is because the later books containing the information have been in the possession of the Court. The number of still-births has not been excessive. There have been eleven cases of puerperal septicaemia in the home since its foundation. During the same period there were 984 outside cases treated. There was one death. The number of infantile deaths is, incomplete, as is the number of still-births. These statistics arc as accurate as it is possible to make them, having regard to the records that have been kept. In my opinion, these statistics show a roost satisfactory condition of affairs. I think we have a great number of bad cases sent to us. We have had a number of eclampsic cases, and we have not lost one of them. We have frequently had cases sent in by other medical men in wdiich complications or danger have been feared. The cases of septicaemia of which notifications have not been produced occurred in 1906-7 and 1907-8. I know that these were reported to the Department. These were the only times when w 7 e really had an outbreak, and the times were anxious ones. The first return of confinements, deaths, &c, put in is not accurate as to still-births. The returns as put in to-day are correct. The return put in to-day shows two months' more w 7 ork than the previous one. At 2.15 p.m. Mrs. Nicol appears, and asks that either the inquiry close or that she get an adjournment till Monday, on the ground of physical unfitness. Further hearing adjourned to Monday, 24th February.

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Monday, 24th February, 1913. On the application of Mr. Mays, who is engaged in the Criminal Sessions of the Supreme Court, further hearing is adjourned till the 3rdJVlarch, 1913, at 10 a.m.

Monday, 3rd March, 1913. Robert Grieve (called by Mr. Skelton), on his oath, saith. lam an Inspector under the Public Health Act, stationed at Auckland. I remember the notice already produced concerning Mrs. Chamberlain. I remember it being handed to me to deal with on the morning of the 10th September. I visited St. Helens Home. I saw the Matron there. I got all particulars I possibly could from her. Mention was made of the isolation ward in the yard. I asked the Matron what she intended to do about it, Mrs. Chamberlain having died in this ward. At this time the body had been taken away. I cannot say if the Health Department was consulted before the removal of the body. Ido not know where the body was taken to, nor do I know who authorized its removal. I made no inquiries about this. I said I would like to see the ward, as I had never seen it. I went with the Matron to look at it. I pointed out that the hole in the ceiling would have to be stopped up before fumigating, and that the walls should be washed down. I offered my assistance, but the Matron said they were quite able to do it, as they had done it as I was suggesting many times before. I took down the addresses from which the patients had come. I knew of Mrs. Porch's case then. She was at the time of my visit in the main building. I returned to the office, and made my report in writing, and asked for further instructions. I was advised by Dr. Monk that nothing further was required. I produce my report to Dr. Monk. [Exhibit No. 57.] The Matron gave me the statement on which I entered in my report the statement that Mrs. Chamberlain's mother was suffering from cancer. I went into the isolation ward. It is lined with galvanized iron, the corrugations of which run horizontally. I say that the whole of the walls should be wiped down with a strong disinfectant, and that the place should be made as airtight as possibles—the ventilator in special being securely throttled and formaldehyde-lamps put to burn in the room. The wipingdown would require more careful doing in the case of a horizontally-lined building, because the dust would lodge on the ledges of the iron. Cross-examined by Mrs. Nicol.] My report is dated the 10th September. The notification does not come to me direct. I did not go and see Mrs. Porch. I did nothing in the way of fumigation. I had no instructions to do more than I did. To the best of my knowledge, the Matron was trusted to do all that was necessary. As a rule, I make all the inquiries in septicaemia cases. I went to inquire into Mrs. Porch's case. That was on the 10th September. I did not see Mrs. Porch. It is not my business to enter the sick-room. There were no other cases of septicaemia there at this time, to my knowledge. Re-examined by Mr. Skelton.] My attention was never called to the case of Mrs. Burns, a laundress at St. Helens during July, August, September, or October of 1912. Cross-examined by Mr. Mays.] I am quite satisfied as to the Matron's knowledge of disinfecting and fumigating. It has been the practice of late to send notices of septicaemia from the General Hospital. The disinfection there is left entirely to the Hospital staff. I have no reason to think that the disinfection is not carried out properly in either of these places. Cases of poisoned hands are sometimes notified to us. We have had cases notified of suspected erysipelas. An ordinary case of blood-poisoning of a finger w 7 ould not be reported to us, unless erysipelas or tetanus were suspected or developing. To the Court.] Mr. Symons, the chief of the clerical staff, would first receive the notifications. If lam available, these are handed to me by Mr. Symons. I then ask instructions from the doctor. As far as I remember, I went to the doctor with the two notifications referring to St. Helens, and told, him I was off up to St. Helens. As a rule, I receive my instructions verbally. After writing out my reports on the case I handed them to Dr. Monk. I asked him if I should visit the homes of the patients, or make any further inquiry, and I was told " No." My reason for making this inquiry was that sometimes such has a bearing on the case. I did nothing further. I cannot say if the rooms were thoroughly disinfected. I know that there are formaldehyde-lamps for fumigating. I have seen them there —that is, at St. Helens. I know also that there are formaldehyde tablets there. I did not ask what fluid was there. Ido not know if the mattresses and other things were burnt. Thomas Hope Lewis (called by Mr. Mays), on his oath, saith. lam a duly-qualified and registered medical practitioner, practising in Auckland. I have seen a copy of the chart in the case of Mrs. Laura Chamberlain, and a copy of her case as recorded in the case-book. I have read through the evidence of Dr. Inglis concerning her case. Forming my opinion from the history of the case as recorded in the case-book and the charts, I say that the case is not inconsistent with bronchial pneumonia or pthisis. Streptococcus can be present in discharges without having at the time any effect on the particular case. 1 have seen the line of treatment adopted. I think it perfectly legitimate and proper. Assuming that the child born there died at the age of six months of tubercular meningitis, and that the tubercle was human and not bovine, and that there were no signs of tuberculosis in the stomach or lungs, my feeling is, after giving it careful thought, that this woman had undoubtedly a latent phthisis. I think that the death of the infant, if it occurred from the cause stated, goes to prove more conclusively that I thought before that my original idea of the case is correct. The case-book and the chart give me no idea of puerperal septicaemia pure and simple. I take the temperature-chart as being the most important piece of evidence in the case. The rise of temperature was so rapid (it came on immediately after labour, which is absolutely non-characteristic of a sepsis due to absorption from the vagina or uterus). The temperature was up in eight hours to

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101-4. Another thing with regard to my contention that the case was not one of septicaemia arising from confinement was this : that if it had been sepsis with peritonitis the woman would have been dead from three to six or seven days. If it had been of a mild character from the same origin she would have had local indication in the pelvis, which would have ended in inflammation and probably suppuration at the end of, say, three weeks. Puerperal septicaemia must end in one of three ways —either rapid death, local manifestations in the way of formation of pus, or with the remains of inflammation in the pelvis without it being of a purulent character. The latter is somewhat rare. From the history of the case, I think the patient had no pelvic complications whatever. To the Court.] From the evidence before me I would not diagnose the case as one of puerperal septicaemia at all. My diagnosis of the case would be that the woman was the subject of a latent tubercle during her pregnancy, and that her condition after the birth of the child was one of rapid development of the tubercular trouble. I see nothing else. I see the death certificate. I cannot alter my opinion with regard to the thing. I see no evidence of puerperal septicaemia in her case. Temperatures are now so very characteristic of a number of diseases that one is able to form a very correct idea of the case without seeing the patient. When temperature arises promptly after confine ment and continues, one immediately suspects that there is some constitutional illness. The thing is too rapid for a septic infection. A temperature which rises quickly about the third day or so will fall immediately on the evacuation of the bowels —that is, when it is due to constipation. I agree with the statement in Williams, pages 78 and 79, and pages 80 and 81, as to temperatures and what they indicate. I have read pages 84 and 85. Ordinarily speaking, the treatment referred to there is sound, A temperature high and continuing high would be very likely due to two causes —infection and chest trouble. As far as the patient's strength would admit, a searching examination should be made to ascertain the cause or causes. If the chart is correct, I would say that the woman was profoundly ill when she came into the home. She had apparently a temperature of 97 and pulse 120. The pulse-rate might be due to excitement, but it only fell to 95 afterwards. Cross-examined by Mr. Skelton.] The medical man in attendance would have a better idea than one speaking from a chart and case-book. Ido not think I have read the evidence of Dr. Goldstein. The examination-in-chief of Dr. Inglis was all that was submitted to me, with, of course, the case-book and chart. With that evidence I have very good reason to say what I have said. It would make no difference if the statement as to influenza is incorrect, and that the patient had a very slight attack some three or four months before. The very first symptom of puerperal septicaemia is stoppage of the lochia. I think Mrs. Chamberlain died from phthisis. I do not know what statements in the chart or book would support Dr. Inglis's certificate that the patient died of puerperal septicaemia lasting some twenty days. If my diagnosis is correct, I would have endeavoured to keep up the patient's strength with suitable foods and a mild irrigation of the vagina. I say she was a very delicate woman. The irrigation would be for the removal of fluids that might become a breedingground for various germs. I might have given quinine or some antipyretic of that character. I would have seen that the bowels had been properly moved. That would have been my treatment. I might not have been able to say at the time that the patient had a chest trouble. Assuming that there was chest trouble, my only treatment would have been to keep up her strength and keep her clean, and give quinine or the like. One would, of course, hope that the temperature would drop, and, if it did not, one w r ould hunt for something being the cause, though I do not say that one would be absolutely certain to find it. I could not make up my mind on the second day that the patient was suffering from chest trouble. I cannot say how many days it would take me to arrive at that conclusion. Assuming I became fairly certain that it was a case of chest trouble, and later became convinced that it was one of bronchial pneumonia, I should possibly have examined the discharges, including quite possibly an examination of the sputum. The sputum —that is the one to examine in a case of bronchial pneumonia. Ido not know 7 that I should advise a blood-test. It might have been of value as giving some information that would have been helpful. Ido not consider a blood-test would be very valuable in a case of sepsis. Ido not say it is absolutely necessary to take a swab from the uterus in a case of puerperal septicaemia. One may be led absolutely astray by the bacteriological examination. Such an examination has a value as a check on the diagnosis. If it disclosed streptococci it might be a very valuable piece of evidence. Ido not know the work of Williams on obstetrics. Ido not know Edgar on " Practice of Obstetrics." I know Allen's work on " Vaccine Therapy." I have not seen the 1912 edition. I very seldom adopt the streptococcic vaccine treatment in cases of septicaemia. The leading maternity homes in the United Kingdom are, among others, the Queen Charlotte and the Rotunda. To the Court.] I have not been shown Dr. Lindsay's evidence. Cross-examined by Mr. Skelton.] Assuming that the patient had bronchial pneumonia, I would prescribe expectorants, bed, and good feeding—nothing else. If there were no improvement after some days I would have a consultant. This woman was doomed from the first. There might he great difficulty in finding out if F there*w 7 ere anything wrong with the chest. Suppose that by the 16th I came to the conclusion that the trouble was one of the chest only, one cannot consider the case one of pure chest when the woman is in the puerperium. Looking back, I say that I think the patient had chest trouble. Assuming that I came to that conclusion on the 16th, and that the patient got no better, I cannot say how long it would be before I took steps to check my diagnosis, because it depends so much on one's own idea as to how seriously ill the woman w r as. Though I have got the temperature, respiration, and pulse, I cannot say how long I would allow 7 the case to go on before taking further steps —that is, where there is no improvement, and temperature rising. I might have a talk with another medical man in a week. Cross-examined by Mrs. Nicol.] Re Mrs. Porch's case, for a primipara twenty-four hours is a normal labour. Sixty-five hours is prolonged. Whether or not the Medical Officer should have seen the patient during that period depends on what sort of labour the woman was in. The second stage was

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abnormal as to time. I could not say from the facts in the case-book that the patient was allowed to remain in labour too long before sending for the Medical Officer. A labour can be hurried beyond normal limits, or it may be delayed. Hyoscine is given to dilate the os. It does not necessarily decrease the time of labour. It might increase it. If the woman were in labour for, say, forty-eight hours, and the labour was strong, the doctor should have been sent for. Hyoscine is worth trying for the purpose of inducing sleep. I see no reason why a dose of hyoscine should not be given by a nurse. It is put up in tabloid form in either a one-hundredth or one two-hundredth of a grain. The pelvic abscess in the case could be caused by something left behind. I cannot say the cause of the onset of delirium. The woman was maniacal. That w r ould account for the rise in her temperature. The prolonged labour might have caused the mania. Possibly the temperature was a sepsis temperature. It might have been, and it might not. The chart is in accordance with a sceptic case. The vaccine injection was given to do the patient good. In a case of puerperal septicaemia I would give the patient beef-tea and milk. I say that is a very good diet, and it is what I w 7 ould order for my own patient. If it is correct that Mrs. Chamberlain's child was in a high fever with much perspiration I do not think that coldpacks should have been applied —that is, if it is correct that it was suffering from, tubercular meningitis. Re-examined.] In the case of tuberculosis the sputum is sometimes very slight. In bronchial pneumonia there is always sputum. I consider that Mrs. Chamberlain was tuberculous, and that it was her general constitutional condition that was lit up by pregnancy and labour. It is not always possible to detect streptococcic infection from a blood-test, The same remark applies to a blood-test for tubercular infection. Re Mrs. Porch : I do not consider mere length of labour a very serious matter —it depends on the character of the labour. The necessity for medical interference must be left entirely to the judgment of the Matron. It is not at all necessary that there should be anything left in the uterus to cause a pelvic cellulitis. Cross-examination by Mrs. Nicol continued.] Hyoscine is used in maternity cases to relieve the pain of labour, to promote dilatation of the muscular cervix, and to produce sleep. As soon as diagnosis of sepsis is made the patient should be isolated. Ido not think there is any necessity for fumigation after an ordinary labour. I should say that when there has been a septic case in any maternity home a thorough disinfecton is most advisable. As to performing a caesarian section, my opinion is that such must be performed to the best of one's ability wherever one is. Only the person on the spot can be the judge as to whether it should be performed or not. There are cases that brook of no delay. The operation could be done with perfect safety in the home, though there was a septic case there. It would not be wise to operate where there are tw 7 o cases of septicaemia in the home. To the Court] I have never been in St. Helens Hospital. I know the building generally. I should say it certainly is not a suitable place for a maternity hospital, I think the site is all right. Such an institution should be well in the city-central. The building could be so constructed as to reduce the noise difficulty. The dust nuisance should be got rid of. I certainly think that a midwife should be able to suture a perinaeum, but I think that in severe lacerations of the perinaeum the duty is more that of a surgeon than a midwife. A mfdwdfe, in my opinion, is not qualified if she cannot attend to lacerations requiring not more than two stitches. In all my large abdominal operations I give hyoscine an hour before the operation. I would call hyoscine an anaesthetic. It is feebly such. It is more a sedative. I call it an anaesthetic because with its use one can do with very much less chloroform or ether after. I should not say it came under the same scale as an anaesthetic as chloroform. Cross-examined by Mrs. Nicol.] I do not think St. Helens should be made an adjunct to the General Hospital. I think it is better as a separate institution. I think that a maternity hospital should be a maternity hospital unto itself. I think the period of twelve months training for a midwife is long enough if the pupil can pass an examination at the end thereof. Jessie Burns (called by Mr. Skelton), on her oath, saith. lam a laundress engaged at St. Helens Home. I have been employed there for nearly three years. I was there during July and part of August of last year. I ceased work for the time being on the 29th August. That was because I had a poisoned hand. It started to swell on the Tuesday, and I stopped work on the Thursday. It began to pain slightly on the 25th, and to swell on the 27th. I have a good idea as to its cause. I think I got the infection from rubbish (swabs and different things) that I got from the isolation ward. I got it in paper from the nurse and put it in the fire. I think one of the nurses had a bad hand at the time. I know that Nurse Elliott had a bad toe. Nurse Peterson was one of those that had a bad finger. She is still at St. Helens. Nurse Jakeman had nothing wrong with her that I know of. Another nurse, I think Nurse Jones, had a bad finger. I am not sure of this. Nurse Edgecumbe had something wrong with her thumb. My hand was chapped, and something got into it, and it began to pain and then to swell. Cross-examined by Mrs. Nicol.] I do not remember the Matron having a poisoned finger at that time. Cross-examined by Mr. Mays.] My hand had not started to fester or suppurate before I was taken off duty. I was sent to the General Hospital for treatment. My hand did not break till the 31st August. I did no work after the 29th August. As soon as the Matron knew she told me to cease work. The nurses at St. Helens have had bad fingers before. To the Court.] I have a good deal of work to do there. The laundry and appliances were quite satisfactory. It is a new place, recently built.

G. IT. FROST.]

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Constance Helen Frost (called by Mr. Mays), on her oath, saith. lam a duly-qualified and registered medical practitioner. Ido the bacteriological work for the Auckland Hospital. I recollect the case of Mrs. Laura Chamberlain. I took a blood-test and a uterine swab in this case. I reported the presence of streptococcus in the swab. The blood-test was negative. As far as I remember, the swab showed the presence of streptococcus. There was no written report. The time was the end of August. I was asked for it orally, and I gave it orally to Dr. Goldstein. I took a swab from another patient a little later. Ido not remember the name. I recollect a child named Chamberlain dying in the hospital recently. A specimen from the ear was sent to me to examine for tubercle by, I think, Dr. Neil. The specimen disclosed the presence of tubercle bacilli plentifully. I was present at a post-mortem on the child. From my knowledge of the case I say that the child died of tubercular meningitis. There were no signs of tuberculosis in the lungs or bowels. I deduce from these facts either that the child was congenitally tubercular or that it must have been in contact with some one who was very tubercular. I think the child is more likely to be tubercular congenitally than as a result of contact with its mother. I used a uterine speculum in taking the swab, but I did not administer an anaesthetic. Cross-examined by Mrs. Nicol.] It was on the 26th or the 28th August that I took the blood-test. It might have been later. After cleansing the skin of the arm I put a hypodermic needle into the vein, I made no saline injection. I drew about eighteen drops of blood. Ido this frequently from, my own arm and those of my assistants. Ido not know 7 the date I took the swab from Mrs. Porch. It was in the main building. As far as I remember, I found streptococci present. I only gave the result of my examination without forming any opinion as to what it indicated. Good foods should decidedly be given patients to assist them to resist the inroads of the germs. To the Court.] In my opinion, the vaccine treatment of cases of puerperal septicaemia is not very hopeful. In some cases the vaccine treatment is very efficacious. The result of the vaccine depends on the patient and the strain of the vaccine that is given. I think the treatment is always worth trying in a case of septicaemia. It cannot do any harm, unless perhaps the patient were weakly constitutionally, or weak from any concurrent disease. Cross-examined by Mr. Skelton.] I remember no statistics on the vaccine treatment in the Lancet last year. I know R. W. Allen's work. Allen is an authority on the vaccine treatment. If it is found that puerperal septicaemia is due to a certain germ I think it is advisable to inject the vaccine at once. In puerperal septicaemia cases I say that, in my opinion, an injection of vaccine cannot do any harm, though I will not say that it is likely to do a lot of good. It is worth trying. Any danger arising from the injection of antistreptococcic serum or vaccine must, I think, be due to the way in which the material is prepared. I see Mrs. Chamberlain's chart. The injection of vaccine on the sth September lowered the temperature. I think that the lowering was due to the vaccine injection. There is a note on the 7th September as to the injection of antistreptococcic vaccine and a fall in the temperature on the same day. There is not fall enough to justify me in saying that the fall was due to the vaccine injection. Re-examined.] If sufficient vaccine is given a fall of temperature is a usual result. Occasionally the temperature goes up immediately after the injection. The question of fixing the amount of the dose is still in the experimental stage. With a good vaccine I think 50,000,000 would be a safe dose. As to chest troubles, the signs of it are not always visible or audible. A case three years ago illustrates this. A patient was reported as suffering probably from enteric fever. A blood-test was negative. I spoke to the patient, a man of forty-five. He said he had never had a cold in his life, had never expectorated, and had never had a pain in his chest. I put my stethoscope to his chest. The left lung was apparently normal, and in the right there were a few crepitations. The patient died, and on examination it was found that his left lung consisted of a piece about the size of a walnut under the collar-bone and the right one was simply full of tubercle. Cross-examined by Mrs. Nicol.] Patients suffering from puerperal septicaemia very rarely havemuch pain. The patient was violent when I took the wab from Mrs. Porch. She appeared to be out of her mind. This might have come on that very day. The patient was in a room by herself. I have had cases of labour extending over a month. As a rule, doctors are more inclined to interfere too soon than too late. An experienced nurse would know if there was any need for the doctor to see the patient during the period of sixty-five hours. Vomiting before labour is common. It is generally a very good sign. It would be due to her stomach being out of order. I would not interfere just because a patient vomited. As to suturing, I prefer to su ure my own patients myself. To the Court.] With an experienced Matron I see no objection to her suturing ruptured perinaeums requiring not more than three stitches. Charles Evans Maguire (called by Mr. Mays), on his oath, saith. I am a duly-qualified and registered medical practitioner, and am acting Medical Superintendent at Auckland Hospital. I recollect a child aged six months, of the name of Chamberlain, being admitted to the Hospital in February ultimo. Dr. Sweet brought the case in. It was suffering from inflammation of the middle ear. The child was the child of Mrs. Laura Chamberlain. [Admitted that the child was born at St. Helens on the 11th August.] The child died in the Hospital. I think it was admitted on the 7th February and died on the 9th. The child w 7 as under the care of Drs. Neil and Sweet in the Hospital. A post-mortem was held. While alive a smear was taken from the ear for microscopical examination by Dr. Frost. I was present at the post-mortem. There were no signs of tubercular condition in the lungs or bowels. Wo wished to discover the ci-aisc of death. We know of the meningitis, and it is our rule to learn as far as possible the cause of the meningitis. The child died, I should say, from tuberculous otitis media and tuberculous meningitis. I should say the state was of human origin probably. The view I took of it was that it was probably due to coniact. I should say contact with

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the mother —assuming that the mother had contact. Seeing that there was infection in the middle ear, I think there was contact with a person's breath. Cross-examined, by Mr. Skelton.] Temperature-charts are not destroyed at the Auckland Hospital. We have no ease-books. We keep history-sheets. These are filed. They contain the original notes made from time to time concerning the case. We use antistreptococcic vaccine at the Hospital. We use it sometimes in cases of puerperal septicaemia. It is a Very moot point whether it be successful. In some cases it appears.to do good, and in others it appears to do harm. We still continue to use it occasionally. I would not say that it is more successful than otherwise. I should think it should be given, as soon as possible after septicaemia has been diagnozed. I know the work of R. W. Allen on " Vaccine Therapy." Allen is an authority on the subject. The dose is a matter for the doctor in charge of the case. The rule is to start with a small dose and gradually increase it. Personally, in an average case of septicaemia I should give about 10,000,000 to start with. It is always somewhat speculative. If the Chamberlain child was taken from its mother five days after its birth it is quite possible that its tuberculous condition was due to coming into contact with some one else. I say that it is impossible to say that the child contracted the disease from which it died from its mother." Cross-examined by Mrs. Nicol] Personally, I should like a maternity wing at the Auckland Hospital. It would be of great benefit to the training of our nurses. I see no objection to a maternity hospital being adjacent to a general hospital. St. Helens is not a hospital, it is a maternity home. It is there to treat natural conditions —not diseased conditions. When the latter arise they are sent to the General Hospital. I should like to see a maternity ward at the General Hospital, apart from St. Helens. Cross-examination by Mr. Skelton continued.] I do not think a recently qualified medical man could be got to take the appointment as resident at St, Helens at £100 a year, because the cases are so few and his experience would therefore be so little.

Tuesday, 4th March, 1913. Thomas Copeland Savage (called by Mr. Mays), on his oath, saith. I am a duly-qualified and registered medical practitioner, practising at Auckland. I saw the chart of Mrs. Laura Chamberlain. [Witness peruses temperature-charts and entries in case-book, also notification to Health Department and certificate of death.] The chart might do for lots of things it depends on her physical condition. One would need to know the result of a physical examination before expressing an opinion on the material before me. I have read the evidence of Drs. Inglis, Lindsay, Goldstein, and Frost. There is no conclusive evidence yet as to what the patient died of. Looking at the chart to begin with, one notes that before the baby was born the woman had a pulse of 120, which, considering that the labour was not a bad one, is conclusive proof that the woman was in bad health from some reason. A woman does not give a pulse of 120 after three hours' labour unless she is ill already. Then we have a death certificate showing that she died of puerperal sepsis. The evidence that she died from this apparently is based on a negative blood-test and a positive uterine swab. A uterine swab, unless taken wnth special appliances, is absolutely useless. We know that in puerperal women the vagina, the cervix, and the cervical canal in from 25 to 50 per cent, of all cases contain streptococci. The only way in which you can get a swab from the interior of the uterus which is trustworthy is to pass first a vaginal speculum, then to catch hold of the cervix with a special instrument to clean the cervix and the cervical canal, then you must pass a sterilized hollow glass tube containing sterilized swab and having over the end that goes into the uterus a sterilized rubber cap with a string attached. After this tube is inside the uterus, by pulling on the string, the cap is displaced, and the swab thrust through the tube on to the wall of the uterus, withdrawn again inside the tube, and taken out. That is the only way that I know of that a trustworthy vaginal swab can be obtained. Unless it was certain that the swab was taken in such a way, there is no proof that the streptococcus came from the uterus. As far as I can understand the evidence given by other people who were in charge of the case, it is quite clear that in the early stages this lady complained of no pain in or about the uterus, the lochia were normal, and she said that in spite of her temperature she felt well barring a cough. I admit that the absence of pain and a comparatively normal lochia are possible in septicaemia, but I have no hesitation in saying that when such does occur the infection is extremely virulent; it is associated with extreme illness and the patient rarely survives more than three or four days. It is inconceivable that a woman can have a streptococcal infection of the uterus without pain. Towards the end of the patient's illness, after the blood-test and the swab, the patient was given vaccine, with no improvement in her condition. I from the chart, that whatever illness the patient suffered from it was the same illness from start to finish. If there is a time at all in puerperal sepsis when in my experience vaccines are of any use it is after the most acute stage is over and the woman has continued ill for from ten to twenty days or thereabouts. Yet here we have a case where the vaccine did no good at that time. Stock vaccines are, as a rule, not so good as those made from the person herself. Other evidence is that the woman had from the commencement of her illness symptoms and physical signs of bronchial pneumonia. This chart is quite consistent with such an illness. The chart is consistent with a tubercular bronchial pneumonia. There is one very suggestive point about this chart—that right along she had a much mor., rapid respiration than one would have suspected from a s pticaemic condition. If I were asked to judge the chart and the history alone I would say that there are still other diseases it might fit in with. If I saw a woman who after labour had no pain about the uterus, and was well enough but for a cough, I would not suspect sepsis, because if she were suffering from septicaemia without pain she would be very ill. In spite of the death certificate, I would not be satisfied that she died of septicaemia. I consider it was prudent to put the woman in the isolation ward, having regard to her temperature, whatever its cause. Having the blood-test and the swab, though not agreeing with the method of'taking

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the same, I would have injected small doses of vaccine for the treatment. It is quite a serious matter and quite a difficult matter to get a uterine swab which is worth anything. I would have taken the swab at the moment there was reason to think the patient was septicaemic, and not before. As to the child, I agree with many of the authorities who state that if you get tubecular disease in very younginfants the infective cause is nearly always the mother. As to what I said before, I say that I would take cultures when I had reasonable grounds for suspecting sepsis. Personally, Ido not suspect sepsis all through that chart. Cross-examined by Mr. Skelton.] I would suspect from pain in the uterus, pain in the vagina, distended abdomen, pain on examination, a look of illness, a complaint of feeling ill, together with a high temperature and rapid pulse. Cases of sepsis where there is no pain and no sign of local infection die within five days of the puerperium. The symptoms in puerperal septicaemia always present are an increase in the pulse-rate, more or less rise of temperature, feeling of illness. Practically, that is all. Ido not think the patient's rapid pulse when she went in would be due to excitement, not with a subnormal temperature. Ido not think it is possible. My experience in midwifery has extended over eighteen years. I should think the doctor who had charge of the case and the doctor who came in on the 28th and remained with it for four or five days would be in a better position than lam to judge what was wrong with, the patient. I think that what the woman suffered from from the start continued right through to the end. lam not sure that I admit that Dr. Goldstein is in a better position than lam to judge what the patient was suffering from. In certain points lam in a better position to judge what the patient was suffering irom than was Dr. Goldstein, who attended her for some days. I say that there is more evidence against the septicaemia theory than for it. I am not necessarily in a better position to judge as to what the woman was suffering from than was Dr. Goldstein or Dr. Lindsay. For these reasons : first, that one of them states in evidence that he could not decide the cause of the illness, but thought it prudent to treat it as a case of septicaemia ; the other says that he did not consider the lung condition satisfactorily accounted for all the symptoms, and he also thought it would be well to suspect it as septicaemia. Yet the result of their blood-test for septicaemia is negative. The whole of the evidence as regards septicaemia from a bacteriological point of view is negative. Personally, I would absolutely disregard the result of the swab. Personally,.! would have taken the swab myself 1 , or seen it taken. I w 7 ould not trust a swab taken from a patient of mine unless taken in the manner mentioned by me. Another reason why lam not necessarily in a less favourable position to judge as to the woman's illness is that one of those who saw her—Dr. Lindsay—states that he has very little experience of septicaemia. I am, unfortunately, not in that position. I cannot answer the question on oath as to whether or not there are symptoms or signs of septicaemia, in the evidence before me, without misrepresenting myself. The chart and all the evidence before me does not suggest to me that the woman suffered from septicaemia at all. Mr. Skelton.] Can you find in the chart and other evidence submitted to you any evidence of symptoms which are usually found in cases of puerperal sepsis ?—I cannot say. To Mr. Skelton.] When I said " I cannot say," I did not understand the question. My answ 7 er to the question is " Yes." There are such symptoms, but those symptoms may be associated with many other diseases, I think the probable cause of death was acute miliary tuberculosis. With a negative blood-culture 1 think the swab did not show the true state of the uterus. Ido not think it possible that it did so, taking into consideration the negative blood-culture. T think, broadly speaking, it would be unwise to permit midwives to suture ruptured perinaeums, though there may be well trained women who are quite capable of doing it. Ido not believe children are born tubercular. The cases are very very rare. Children born of women who are tubercular are prone to develop tubercular trouble —that is, they are born susceptible to it. If a child taken from its mother on the fifth day died at six months from tubercular trouble I should regard that as strong presumptive evidence that its mother or father were strongly tubercular, and that it inherited from one of them, more probably the mother, a strong tendency to tuberculosis Provided streptococci are found in the blood-stream, then I should use vaccine. [Lancet of 28tb December, 1912, page 1799, " Vaccines and puerperal septicaemia," put in.] In my experience, I never use vaccines early, but they are of some use in later stages provided organisms are found in the blood-stream. To the Comt.] It does not seem to me possible that the woman was suffering from bronchial pneumonia and septicaemia together. I have been in St. Helens Home once. I should not think its site a suitable one for a hospital of this character. I think it would lead to a greal deal of confusion if the maternity hospital were, placed near to the General Hospital. It should be quite a long way from the surgical, typhoid, and infectious wards. I think it would be better to be quite by itself. lam not in a position to say anything about the suitability of the present building. I know the drug called hyoscine. While I use it a lot, I never actually administer it. Ido not think it should be administered without communicating with the doctor. In bronchial pneumonia there is no need to examine the sputum early. Examination of the sputum would give evidence as to the germs in the lung, but none as to the extent of the disease. If the attendant is a skilful man he can tell by an examination of the chest if the patient has bronchial pneumonia. Cross-examined by Mr. Nicol.] I see the charts relating to Mrs. Porch. I say that the patient was suffering from some pelvic infection with an abscess. That is what it looks like. Apparently the patient has sepsis. If I knew that a nurse was suffering from a vaginal discharge I would not permit her to attend to a maternity case. Re-examined.] As a general principle the insertion of sutures and the administration of hyoscine should not be left to a midwife, but if I knew 7 the midwife to be trained and capable I would have no objection to leave these matters to her —that is, I would not permit it, with a reservation ir favour of certain individuals whom I knew to be capable. [Mr. Mays says this is the end of his case, and that he has no further witnesses except Dr. McDowell.]

H.—3lb.

92

F. KELLEII

Florence Keller (called by Mrs. Nicol), on her oath, saith. [Mrs. Porch's temperature-charts and copy of case-book entries relating to her case are perused by witness, and also Mrs. Porch's written statement. Mrs. Porch's evidence on oath is read over to the witness. General Hospital chart and history perused by witness as well as extract from operation-book.] Examined by Mrs. Nicol.] I have seen Mrs. Porch. Her mental state was perfectly normal when I saw her, which was about four weeks ago. I think her capable of writing out the statement which has been produced, and which purports to be made out by Mrs. Porch. I consider the period of the first stage of her labour a long one. The second stage—five hour- I —l consider a long period. I consider a labour of sixty-five hours' duration an abnormal labour. I have had eleven maternity cases in the last two weeks. That is a little above my average. I speak from my own experience and from books I have read. I consider that the medical attendant should have been called in during Mrs. Porch's labour. I consider that if labour has been going on for twenty-four hours a medical attendant should be summoned. I have told them at the Salvation Army Home to send for me in every case if the labour is prolonged more than twenty-four hours. These are cases for which lam not paid. Ido not think it right for a Matron who is a certificated midwife to put in stitches where the perinaeum is ruptured. My answer extends to all ruptures —small and great. From the chart I see that Mrs. Porch was twice given hyoscine. That is to relax and dilate the os. I would myself give hyoscine, —that is, I would prescribe the dose. I would not leave that to a midwife. I haye not seen the, labour-bed at St. Helens. At the Salvation Army Home there is a labour-bed composed of a horsehair mattress, having springs in it, upon a common ironing-board, which is placed on the ironwork of the bedstead. On the mattress is a blanket, over that a macintosh, then another blanket, and then a sheet. Mrs. Porch could have been put in a sitz bath. I should have thought it would have been a wise thing for Dr. Goldstein to have seen Mrs. Porch when he was in the home in the morning o the day of the birth. I would consider that it amounted to a duty of the doctor to go and see the woman. Ith nk medical aid should have been called in at the end of twenty-four hours. I think it would have been wise to have done artificial dilitation at the end of the second day. Other steps could have been taken. I would say that the prolonged labour would be a factor in the woman's mental state ; that is mainly owing to sleeplessness. I should say that septic infection started on the second day. The septic infection would be another factor in the delirium. Pressure is generally appli' dto the abdomen to ascertain if there is any tenderness. If there is, one is suspicious of septic infection. For a septic patient I would prescribe slop foods and a milk diet. Septic infection would be the cause of the abscess in the pelvis. If the streptococcus germ got in it could have been caused by membranes or part of the placenta being left in. I believe in the injection of vaccine in connection with sepsis. I have used it for thirteen years. I say it was not right to keep Mrs. Porch with other women, though the isolation ward was full, when it was found that she was septic. I think it would be all right to perform a caesarian operation in the Hospital. After every patient leaves the wards should be disinfected. Mrs. Nicol.] Would you permit a nurse suffering from a vaginal discharge [Mr. Mays objects to the question Commissioner tells Mrs. Nicol that the question contains an ins nuation, and she must either withdraw the insinuation or state that she is prepared to prove her insinuation. Question not pressed.] Cross-examination continued.] I would call two hours a quick confinement. I would not call twenty-two hours a quick confinement. I remember a puerperal case at the Salvation Army Home. I remember one in six years. There are seventeen beds in the Army Home. The Matron was isolated on account of the puerperal case. The case was sent to the General Hospital. The period of isolation was a month. For a blood-test I would take the blood from the ear or the tip of the finger. I have not known a blood-test taken from a vein in the arm. I cannot account for Dr. Frost taking twenty drops from a vein in the arm unless she was going to inject saline. I w 7 as allowed to suture after I graduated. Whether I would treat a cough or not after confinement depends on the nature of the cough. Ido not consider it right for the nurse to have nursed Mrs. Porch, so soon after nursing Mrs. Chamberlain, till her death—that is, from an infectious standpoint, even though both were suffering from the same complaint. I was once refused help by a member of the British Medical Association —by Dr. Scott. He said that it was because I was not a member of the British Medical Association. He told me he would not be allowed to go to my help by the president, Dr. Inglis, unless he went with a solicitor. The case was a very serious one at Onehunga, and on Dr. Scott's refusal to come without the permission of the British Medical Association I came to town and got my husband and Dr. Stopford, and so satisfactorily completed the case. Cross-examined by Mr. Mays.] Two days is, I think, the longest period of labour in connection with any case of mine. I did something in this case, but Ido not know that it had the effect of shortening the period. I have shortened the first stage by artificial dilitation. Before doing so one makes certain that the patient is in a fit state to stand it. To do it prematurely may mean to impair the cervix. This may have a bad after-effect on the patient. As to Mrs. Porch's case, as Ido not know what was the condition of the cervix, I am not in a position to say what I would have done. An experienced trained midwife ought to be in a position to know the condition of the cervix. The only fault I find is that the Medical Officer did not go and see the patient when informed of her condition by the Matron. I approve of the principle of bringing about a confinement as naturally as possible. My experience of hospitals is that in.infectious diseases wards a nurse remains on duty for two weeks, and then in isolation for two weeks. As to the same nurse having nursed Mrs. Chamberlain and then Mrs. Porch, there is a risk to the second patient in the event of the diagnosis that both were suffering from the same disease being wrong. This same danger is common to all infectious-diseases wards or hospitals. I have not read the evidence relating to Mrs. Porch's case. To the Commissioner.] There are many cases at the Army Home that I never attended. There are about 100 cases there per annum. lam not sure of this. I would like to look it up. There has been but one death at the Army Home. lam not in a position to give evidence on statistics. Adjourned to the sth March.

W. C. W. MCDOWELL.]

93

H.—Blb.

Wednesday, sth March 1913. William Chisholm Wilson McDowell (called by Mr. Mays), on her oath, saith. I am a duly-qualified and registered medical practitioner, practising in Auckland. I have been practising here for seventeen years. To the Commissioner.] I visited St. Helens Hospital for the first time yesterday. I am not in any way connected with the institution, and am wholly unbiased. The present building is not suitable for the purposes of a maternity hospital. A great objection to it is that it is not all fireproof, as it should be. I think the situation is good for the patients who are likely to avail themselves of it. If it were possible to add to the grounds, I think the site quite suitable for an up-to-date building. Of course, the proximity to the tram-line is an objection on account of the noise. I questioned patients yesterday who were on the side nearest to the tram-lines as to whether they were affected or disturbed by the noise. Those of them who came from the town said, " Not at all," those from the country said that after the first night or two they did not notice the noise. It is a great advantage to be near the tram-line. If the building were further from the street no doubt that ground of objection would bo removed. As to the dust nuisance, that could be done away with by the city authorities. I have been wondering if it would be possible to have a branch establishment somewhere in the neighbourhood of the growing districts about Kingsland or Dominion Road. As to whether the Matron of the institution, being a qualified midwife, should be permitted to suture ruptures of the perinaeum when the services of a medical man can be obtained, that depends on the nature and depth of the rupture. The experience of the Matron of such an institution as St. Helens must be greater than that of the ordinary niidw 7 ife, and she should no doubt be competent to deal with ruptures that are not serious. As to serious rupture , I think the services of a medical man should be obtained to deal with them. If there is any doubt as to whether the rupture is serious or not, then it would be better to leave it in the hands of a medical man. I w 7 as going to suggest that it would be well to have a deputy medical man who would be available when the Medical Officer could not be got. If the services of the medical man, were available I think he should be called in to attend to ruptures. Ido not doubt the competency of the Matron, but I think it would be better to have the medical man. I think that all drugs of the nature of hyoscine should be administered under the direction of the medical attendant. Ido not agree with general directions on the matter. There should be directions relating to each case — whether they should be written or not is another matter. As to a first labour, if the waters have not broken, twenty-four hours is not an excessive time. In a first labour it is well to let the labour continue as long as possible, if the mother and child are not suffering. There is then less danger of rupture of the perinaeum. If the water has broken, then delivery should take place as soon as possible. Ido not think the time allowed in Mrs. Porch's case was an unreasonable time to allow for the two stages —the second and third stage. To Mr. Mays.] I do not regard a rupture of the perinaeum not going to the muscular tissues as making the confinement abnormal. A rupture of the first degree is the most common form of rupture. Under the rules the Matron would be justified in not sending for the medical attendant if the only incident of a confinement were a rupture of the perinaeum of the first degree unless it were an extensive rupture of the first degree. It is better to have the suturing done as soon as possible. Hyoscine is used as a preliminary to anaesthesia. It lessens the amount of drug required to produce anaesthesia. It is not an anaesthetic in the ordinary use of the w 7 ord. It is a sedative. I would not call hyoscine an anaesthetic. I see no great objection to the Matron giving hyoscine under general directions relating to specific conditions. Personally, I think the medical attendant should see the patient before the drug is given. Mere length of time of labour is not an abnormality. Patients differ so much that I think the doctor should prescribe in each case. In my opinion, it is safer that the instructions should be direct instructions. I think it is safer if the Matron were to get specific instructions from the Medical Officer in each case, if possible. 1 say that an experienced Matron would probably administer such drugs safely, but I think it better to get directions from the medical man in individual cases. It should be left to the Matron to decide when she should send for the medical attendant in a prolonged labour. Personally, I think that the doctor should advise for each case as to the administration of powerful drugs. I think a good deal should be left to the medical director of the home on points not covered by the regulations. An experience of six or seven years in an institution of the kind should give the Medical Officer a pretty good idea of what is safe or unsafe. Cross-examined by Mr. Skelton.] I have not much objection to a Matron of such a home as St. Helens putting sutures in small ruptures, but, personally, I think they should not do so in ruptures of the second degree —by the second degree I mean ruptures extending into the muscular tissue. Cross-examined by Mrs. Nicol.] Danger of sepsis is greater with a large wound. It is desirable that there should be as little noise as possible about the home, though it must be remembered that the patients are not suffering from illness, as are those in a general hospital. I think a little noise would not do the patients in a maternity home much harm. I do not think it is part of the duty of an ordinary nurse to suture in maternity cases. Obstetrics usually come under the guidance of a physician, but there is no reason why a surgeon should not have charge of a maternity home. In the case of small operations being required, the appointment of a surgeon might be of advantage. I see no objection to a surgeon who does the dirty surgical work of the General Hospital presiding over St. Helens, presuming that the surgeon takes every precaution in making himself surgically clean. I presume that such would be done by every surgeon connected with our Auckland Hospital. A physician attending, say, a scarlet-fever case might easily bring more danger into a home than a surgeon attending a septic.case. The same applies to a nurse. lam aware that a physician attends to maternity cases in a general hosiptal. Of course, the two branches of the profession are combined in this country. I see no reason for Dr. Goldstein seeing Mrs. Porch on the morning of the day of her confinement when he was in the home unless he had been requested by the Matron so to do.

H.—3lb.

94

j[W. C. W. MCDOWELL.

To the Commissioner.] I think pupil nurses should be permitted to conduct confinements and examine patients during their course of training. I think that the Matron or submatron being certificated midwives should be present at every confinement. I think that pupil nurses should share in the delivery. If possible, the Matron or submatron should be present. I think that pupil nurses if they are attending confinements outside should do so in the presence of the Matron or submatron or a medical man. I see no objection to a pupil nurse going in emergency cases and doing what she can till the Matron or submatron are available. I would like to add my testimony to the absolute cleanliness of St. Helens Home. Ethel Dora Jakeman (called by Mrs. Nicol), on her oath, saith. lam a pupil nurse at St. Helens. lam twenty-five years of age, and have been nearly nine months at St. Helens. I paid my £20 to get in. I make no complaint about the fee. lam quite satisfied, and think it a fair thing. One gets a good training and free board and lodgings for twelve months. I was not present at Mrs. Porch's delivery. I took the patient on shortly after delivery under instructions. I cannot say who prepared Mrs. Porch for her confinement. I thought Mrs. Porch was a little strange from the first —even when she first came in. I saw her before the child was born, and I thought she had a strange manner. Anything I did for Mrs. Porch was put in the nurses' report-book. Mrs. Porch was peculiar in her mmd —-she was very peculiar. I had nothing to do with Mrs. Porch's temperature or pulse. She was only the seventh or eighth case I had had after confinement. Ido not think she ever had her baby at her breast. Ido not think she would nurse her baby. There was always somebody with her. We had an awful job to get her to take food. One of the senior nurses took her temperature. Ido not remember if any of the nurses had poisoned hands during July, August, or September. I have never had a sore hand while there. I remember a nurse having a sore finger, but she was off duty all the time. One or two nurses have suffered from sore hands, but they were never on duty during that time. Ido not remember any nurse having sore eyes. I remember now that one nurse had sore eyes, and was off duty for a couple of days. I knew that Mrs. Porch and Mrs. Chamberlain were supposed to be septic. I did not know at the time. I did not know that Mrs. Chamberlain had been septic till after her body was taken away. I knew that she was isolated. I knew that would be for something infectious. I never understood that Mrs. Porch was septic. I received special instructions from the Matron regarding the presence or supposed presence of septicaemia. I was told to be careful in everything, and to have everything disinfected. I was not permitted to have anything to do with any other patient. Nurse Stevenson assisted me in nursing Mrs. Porch. I had nothing at all to do with Mrs. Chamberlain. Of my own knowledge, it was talked about that there was sepsis in the home. That was latterly. Mrs. Nicol.] During the time Mrs. Porch was in the Hospital, or during the time Mrs. Chamberlain was in the Hospital or isolation ward, was there any talk amongst the nurses, to your knowledge, with regard to suspected septicaemia ?•—No ; I do not think there was. To Mrs. Nicol.] I did not sleep in Mrs. Porch's room. I slept in my usual room. There were four of us there. It is a good large room. I slept in the room with the other nurses up to the time Mrs. Porch went to the isolation ward. I had a bath every day. The nurse did not ask me to take any extra precautions during that time. I did not know that Mrs Porch was septic. I did not think she was septic I have been to outside cases The Commissioner.] During the time of the high temperatures in the case of Mrs. Porch and Mrs. Chamberlain, did you or the other pupil nurses receive any special instructions or warnings from the Matron or the submatron or medical attendant ?—Yes. The Matron gave me instructions. I was told to thoroughly disinfect my hands. I cannot exactly say what instructions I got. To Mrs. Nicol.] I went about the house in the ordinary way. In outside practice I have always been accompanied by the submatron. In outside cases I have had no cases of confinement with rupture of the soft parts of the perinaeum. I have not been taught to suture. Ido not remember what food Mrs. Porch had. As far as I can remember it was just drinks. I was on day duty with Mrs. Porch. Now and again I got up at night if she wanted anything. My bedroom was downstairs. The night nurse would come down and tell me if anything were wanted. She could sit at Mrs. Porch's door. I suppose you would say that the night nurse had charge of Mrs. Porch during the night. lam quite satisfied with the food at the home. Cross-examined by Mr. Mays.] I had nothing to do with Mrs. Chamberlain. As to Mrs. Porch, I had to do everything for her —by night or day. I saw her chart. I was instructed to be very careful in every way—that everything was to be disinfected ; and I was to have nothing to do with any patient but Mrs. Porch. I was not told exactly what disease Mrs. Chamberlain or Mrs. Porch were suffering from when put in isolation. I thought perhaps it might be something infectious. I did not hear till after Mrs. Chamberlain's body left what disease she was supposed to have died of. I think there was discussion amongst us as to the cause of her death. So far as I remember none of us knew authoritatively what Mrs Chamberlain died of. We are told to take precautions in all cases of high temperature. I had nothing to do with any other patient whilst I was attending to Mrs. Porch. I had an ordinary daily bath while attending Mrs. Porch. I regarded Mrs. Porch's case as a mental one. Pupil nurses are not told by the medical attendant in serious cases what the patients are suffering from. Mabel Davis (called by Mrs. Nicol), on her oath, saith. lam a married woman. Just over four years ago I applied to be admitted to St. Helens. It was in September I saw the Matron at St. Helens. I got in and paid £1. I was confined there of my third child. Certain things were not satisfactory. I have complaint to make against the home. The Matron informed me that I was not to come till labour had set in. I told her that I had very quick labour, and would not have time—that it was very often all over within an hour. I was living at

M. DAVIS.]

95

H.—3lb.

Ponsonby. She said it did not matter, I could not come in till I started to be bad. The consequence was that I got into the tram, and my child was nearly born there. When I got out of the tram I collapsed outside the fire station, and the nurses had to come and pick me up. The motorman stopped the car to permit me to get out. I was partly carried into the home. There they stated that the rule was to put me into a bath. I said, " Don't put me into a bath." When I got into the bathroom doorway I collapsed on the floor, and my baby was born in the doorway. I was lifted from there on to a board in the corner of the bathroom. It was a plain wooden board covered with a blanket. The door and the window from the bottom were open —opposite to each other. I was asked as to my husband's wages. I was told that if they averaged over £1 ss. per week that I could not come in. I was admitted. My husband was not working at the time. I got no instructions from the Matron as to the Medical Officer. I left on the thirteenth day after my confinement. I was then as well as could be expected. I w 7 ould never go into St. Helens again. Cross-examined by Mr. Mays.] I am certain that I was told that if my husband was earning more than £1 ss. per week I could not be admitted. At that time w 7 e had no home. We were in rooms. I did not know that I could have remained in the house as an outpatient at a cost of £1. We got a house a fortnight before I went into St. Helens. . To the Commissioner.] I was twelve or thirteen days in the home. It cost me £3. I told the Matron when I expected to be confined within a few days of the date. Ido not know the name of the Matron. [Mrs. Nicol says that she has no further witnesses to call. Mrs. Nicol states that she does not wish to give any evidence on oath on her own behalf. Mr. Mays states that he has no further evidence.] Cornelius Little (called at the request of Mrs. Nicol), on his oath, saith. I am an undertaker, carrying on business in Hobson Street, Auckland. I know St. Helens Maternity Home. I hold no contract for the interment of the dead from St. Helens either from the Government or the Public Health officials. I have had some interments from St. Helens. Relatives ask me to carry out interments, and Ido so. From memory, I should say I have had but four interments of adults during the last six years. There may possibly have been more, but Ido not remember. Three years ago there were two, and two within the last two years. I cannot say as to the deaths of infants. I should say I have had about a dozen interments of still-born children during the six years. For my own protection, I always inquire what the deceased have died of. lam not too sure that I remember Mrs. Chamberlain's case—if it is the case I think of I embalmed her. She appeared to have all the symptoms of kidney-disease. The husband told me she had been treated for kidney-disease. In embalming I open an artery. I cannot say from memory if the body was swollen. I form an opinion as to the cause of death for my own use. lam aware that it is of no use here. I buried Mrs. Catchpole. The cause of her death was delirium tremens. Dr. Maguire, at the General Hospital, signed the death certificate. To the Commissioner.] I cannot say now who authorized me to remove the body of Mrs. Chamberlain from the isolation ward at St. Helens. No objection at all was made to my removing it. I would not be certain if I went there myself or sent a man. I know the isolation ward. I have been in there twice. I did not know at the time that she was supposed to have died from puerperal septicaemia. To Mrs. Nicol.] My custom is to remove the body in a shell to my place, then remove it from the shell and embalm it, and if the proper coffin were finished in time to place the body in it for the relatives to see it. [Re Mrs. Catchpole, Mrs. Nicol states that she wishes to formulate a complaint against the administration with reference to this woman. She states that she has not formulated it before because she has not had an opportunity. Mr. Mays hands in document dated 3rd March, 1913, from Ann Coombe, mother of Mrs. Catchpole, objecting to her daughter's case being inquired into. [Exhibit No. 24.] Commissioner informs Mrs. Nicol that if she will formulate her complaint as to Mrs. Catchpole, and call her witnesses, the matter will be investigated. Mrs. Nicol states that she will not formulate a complaint. Mrs. Nicol again states that she does not wish to call any further witnesses on this inquiry. Mrs. Nicol again states that she does not wish to give any evidence herself. Commissioner hands to Mrs. Nicol a copy of the evidence, which she undertakes to return to Mr. Skelton on demand.] Adjourned to 7th March, at 10 a.m.

Friday, 7th March, 1913. Tracy Russell Inglis (recalled by Mr. Mays), saith. I recollect the incident referred to by Dr. Keller in connection with Dr. Scott. At that time I was president of the Auckland Branch of the British Medical Association. Dr. Scott rang me up before the time fixed for the set operation. He asked me for my ruling on a particular case. He then detailed the circumstances, and said that he had been asked to assist Dr. Keller at an operation that morning. I told him that seeing it was an urgent case, and Dr. Keller first approached him, he undoubtedly should go, but.if so many hours had elapsed, and Dr. Keller had fixed an hour for the operation later on in the morning, in my opinion it then ceased to be an urgent case. [At this stage of the proceedings Mrs. Nicol hands in a further complaint re Mrs. Amelia Catchpole. Mr. Mays protests against the complaint being admitted, on the ground that Mrs. Nicol has not the consent of any person on behalf of the relatives of Mrs. Catchpole.] To the Commissioner.] I have read the complaint. Mrs. Catchpole was a maternity case. She was not suffering from the complaint mentioned wffien I sent her to the Hospital on or about the 4th February, 1913. I saw the patient at her private house. She was being nursed by St. Helens nurses for her confinement. She had just been confined at her own house. She was confined on the night

H.—3lb;

96

[t. c. inglis.

before she was sent in to St. Helens. She was sent to St. Helens on my authority. Bad cases in the district are sent in to the home. I cannot remember the rule under which I sent her in—l understood that the Medical Officer could admit patients at any time. It has been the practice to remove outside cases which are being attended by the St. Helens nurses into St. Helens after confinement in their own houses when there is need for more careful attention—that is, if complications arise and they require more supervision and nursing. Mrs. Catchpole remained in the home for about two days. She then developed the trouble stated in the charge, and on the authority of Dr. Valintine and Miss Maclean she was transferred to the District Hospital. I was called to the patient at her house on the morning after her confinement. Her sister informed me that she had had a fit. In. view of that statement, and from the fact that eclampsia is a very serious complication, I had her removed to St. Helens. I had previously warned her people of the possibility of the disease mentioned in the charge developing 'at the time of her confinement, and explained to them that it would be serious if it did happen. It is probably correct that the patient was admitted to St. Helens on the 3rd February, was transferred to General Hospital on the 4th February, and died there on the sth February. I think the date of birth was at least a day and a half before removal to St. Helens. I was not present at the confinement. Mrs. Catchpole had engaged a St. Helens nurse to attend her. She had previously been a patient of mine. I w 7 as called in after the confinement. I suppose the history of the case would be got at the General Hospital from the patient or from whoever accompanied her. It was a premature confinement. To Mr. Mays.] It was an emergency case. The patient lived comparatively close to St. Helens. It would not have been a proper thing to have allowed her to have remained in her own home from the time I saw her onwards. I cannot say what nurses were attending her. The patient's husband was, I think, an ordinary working-man. His wife would be eligible for admission. The patient was transferred to the General Hospital for the reason that she was disturbing the rest of the patients at St. Helens. I got authority from Dr. Valintine to transfer her. This inquiry was on at the time. Cross-examined by Mrs. Nicol.] I have no knowledge of a room being engaged in a private home or hospital for Mrs. Catchpole for her confinement. I have attended her and her family privately for years. I did not know that she had made application at St. Helens for St. Helens nurses to attend her. Mrs. Catchpole spoke to me about three months prior to the time she expected to be confined. She gave me an address —Charlotte Terrace, off Cook Street. She came to me, I suppose, because I was the family doctor. I was under the impression that the confinement was to take place at her own house, Charlotte Terrace. She afterwards removed to her mother's house. There the miscarriage took place. I knew 7 nothing beyond this of any arrangements she had made or contemplated making as to her place of confinement. I told the mother myself that I would not take the responsibility of either I myself or the nurses attending to her in that house. This was after the miscarriage. St. Helens nurses were sent on emergency. I think some of either the neighbours or her own people called, and asked the nurses to go. I had nothing to do with the St. Helens nurses going there. I saw the patient on the day she was moved, I saw her twice that morning. I know that Mrs. Catchpole gave me her consent to going into St. Helens. At first she said she did not want to be moved. After explaining the circumstances she consented to go. I arranged to get her removed straightaway. Her condition was serious. I sent her to St. Helens as being the proper place to send her to. I dealt with her at St. Helens as far as I could. When she developed further symptoms she was transferred. She was too rowdy for the rest of the patients to be kept at St. Helens. I did not think the isolation ward was the proper place for her. I consulted with Dr. Valintine, and as a result the patient was sent to the District Hospital, Ido not think the removal to the General Hospital made the slightest difference to the patient. She was not delirious when I sent her to St. Helens. All the history I got was that she had had a fit. I w r as present when the statement was got from Mrs. Coombes. It was at her house. There were present Mrs. Coombes, Mr. Mays, and myself. The deceased's husband was not consulted about it. I went at Mr. Mays's request. The statement was written at the house, and it was signed there. I had not seen Mrs. Coombs on the matter before we went there. I did not tell the mother the cause of the daughter's death. I did not inform the husband of the cause of his wife's death. I did not tell the mother that her daughter died of heart-failure. I had not seen the mother from the time the woman was removed to St. Helens till I went to see her the other day with Mr. Mays. Re-examined by Mr. Mays.] I am aware that the mother did know the peculiar weakness of the daughter. The deceased's sister knows the cause of the deceased's death. The sister told me. The husband knew of his wife's habits. I warned him about his wife's habits. That was, I think, a month or six weeks before the miscarriage. I was present at Mrs. Coombes's house when Mrs. Coombes signed the statement. The statement was given and signed quite voluntarily. I had no reason to suspect a miscarriage and a birth at six and a half months on account of the habits of the woman. From the time I w 7 arned the husband till the miscarriage I had no information as to whether she was continuing her habits. Her condition was not so bad when she was removed to St. Helens as it was when she was removed to the General Hospital. None of the relatives has ever made any complaint to me whatever. Cross-examined by Mrs. Nicol.] I made no statement to Mrs. Coombes that if she came to Court with a weak heart she might drop dead. She told us that it would nearly kill her to see her daughter's case discussed in Court. The baby breathed, but it was not viable. It was taken to St. Helens. I do not know that it was sent from there to the mother's home again. The child could not live. To the Commissioner.] I arranged over the telephone with Dr. Maguire for the woman's admission to the General Hospital. I gave the history to Dr. Maguire over the telephone. I should not think it would be the one written down on the history-sheet. The history there written is not correct. That often happens. Re Mrs. Porch : I operated on Mrs. Porch at Mr. Gillon's request. When I consented to do it I did not know it was Mrs. Porch. I did not know till she was on the table.

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To Dr. Keller (through Commissioner).] I think it was early in the morning that Dr. Scott rang me up. I suppose he did so because I was president of the medical association. He asked my ruling as to whether it was an emergency case or not. You came under the classification of practitioners that we did not wish to consult with —except in emergency cases. As far as I have said, all that you have said with regard to the matter of Dr. Scott and yourself is true with the exception of the statement that she was not met in consultation because she was not a member of the British Medical Association. A certain number of practitioners were imported or otherwise obtained by the friendly societies to take the medical work at a lower rate than we thought right and had been accustomed to. I know that Dr. Keller was practising in New Zealand long before that. Dr. Keller's husband took up w 7 ork tinder the friendly societies. Dr. Keller consulted with her husband and the rest of the practitioners to which I have referred. To Mr. Mays.] The case referred to by Dr. Keller was not an urgent case in the way it was put to me by Dr. Scott. I have never allowed the relations between the members of the British Medical Association and the doctors to which I have referred to interfere with me in my public positions — that is, as an honorary surgeon at Auckland Hospital and as Medical Officer at St. Helens. [Mrs. Nicol states that she unreservedly withdraws the imputation conveyed in her question to Dr. Savage as to a nurse suffering from a discharge.] Inquiry adjourned sine die pending the decision of the Supreme Court on question to be submitted thereto.

Wednesday, 26th March, 1913. All parties present. Commissioner read letter dated the 7th March received by him from the secretary of the Auckland United Friendly Societies. Mrs. Nicol asks Commissioner to call the persons mentioned in the letter —viz., Messrs. Nerheny, Beehan, McLeod, and Gray—as witnesses. Mr. Skelton states that, having given the matter very careful consideration, he admits that the dispute between the friendly societies and the British Medical Association is not a matter into which the Commissioner can be asked to inquire. The Commissioner ruled that he could not inquire into the dispute between the friendly societies and the British Medical Association, but that the letter received by him would be forwarded with the exhibits and his report. Mr. Mays handed in the order of the Supreme Court on the special case which had been stated by the parties. Mr. Mays contends that, apart from the decision of the Supreme Court, the Hon. the Minister objects on the grounds of public policy to the case-books and charts being inspected by any one except the Commissioner. Agreed by all parties that Mrs. Nicol's address on the evidence be now taken, pending furtherdiscussion re inspection of case-books and charts. Mrs. Nicol commenced her address. Adjourned to 27th March, 1913.

Thursday, 27th March, 1913. Mrs. Nicol's address continued and concluded. Mr. A. E. Skelton addressed the Commissioner at considerable length, especially on the Chamber lain case. After discussion Mr. Skelton says that he does not now press his application to inspect the casebooks and charts, but requests the Commissioner to carefully inspect them with a view of noting the number of cases in which there was a i uptured perinaeum sutured by the Matron, &c. Inquiry concluded.

13— H. 31b.

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EXHIBITS. Nos. 1. Plan of site. 2. Plan of building'—Ground-floor, upper floor, basement, and isolation ward (three sheets—A, B, and C). 3. Temperature-chart (three sheets —A, B, and C) of Mrs. Laura Chamberlain. 4. Temperature-chart (one sheet) of Mrs. Mary Stevenson. 5. Copy temperature-chart (two sheets—A and B) of Mrs. Martha Porch. 6. Another copy temperature-chart (two sheets —A and B) of Mrs. Porch. 7. Notes, treatment, &c, of Mrs. May Brown. 8. Temperature-chart, &c, of Mrs Brown at General Hospital. 9. Temperature-chart, &c, of Mrs. Brown at General Hospital, 10. Temperature-chart, &c, of Mrs. Catchpole at General Hospital. 11. Temperature-chart, &c, of Mrs. Bessie Brown at General Hospital. 12. Temperature-chart, &c, of Mrs. Mary Stevenson at General Hospital. 13. Temperature-chart, &c, of Mrs. Julia Cartledge at General Hospital. 14. Bundle of forms used at St. Helens Hospital. 15. Bundle of monthly returns. 16. Bundle of reports. 17. Letter dated 7th March, 1913, from Secretary Auckland United Friendly Societies Dispensary to Commissioner. 18. Letter (undated) and telegram (8/3/13) from John W. Neagle to Commissioner. 19. Letter dated 30th January, 1913, from Miss E. A. Rout, Christchurch, to Commissioner. 20. Letter dated 20th January, 1913, from Arthur Cummings, Grey Lynn, to Commissioner. 21. Rules framed by the Central Midwives Board, London, under Section 31 of the Midwnves Act, 1902 ( Edw. VII, c. 17). 22. The Lancet, 28th December, 1912. 23. Magazine, January, 1912 (No. 1), on Obstetrics, &c, pages 102 et seq. 24. Memo, dated 3rd March, 1913, signed by Ann Coombe. 25. Letter, 29th October, 1912, from Bradney, M.P., to Mrs. Nicol. 26. Extract from Star, 20th July, 1912, re St. Helens Hospital. 27. Letter, 22nd July, 1912, Mrs. Nicol to Hon. Minister of Internal Affairs. 28. Admission forms, St. Helens Hospital 29. List of books, &c, kept by Matron and others at St. Helens Hospital. 30. Nurses' report-book from 22nd October, 1912. (Note. —Report-books prior to this destroyed). 31. Delivery-book from 24th August, 1912. 32. Statement (undated) by Mrs. Porch. 33. Extract from General Hospital operation-book re Mrs. Porch. 34. Letter —29th August, 1912 —from Matron to Miss Maclean, Inspector. 35. Letter —sth September, 1912 —from Matron to Miss Maclean. 36. Letter —11th September, 1912—from Matron to Miss Maclean. 37. Letter—l7th August, 1912— Mrs. Nicol to Hon. Minister. 38. Letter (second) —17th August, 1912—from Mrs. Nicol to Hon. Minister. 39. Letter—2nd September, 1906—Mrs. Nicol to Hon. Minister. 40. Letter—l6th July, 1912—Mrs. Nicol to Prime Minister. 41. Letter—6th August, 1912—Mrs. Nicol to Hon. Minister. 42. Letter—23rd July, 1912—from Mr. Dickson, M.P., to Hon. Minister. 43. Letter —I6th July, 1912—(in Mrs. Nicol's handwriting) from Secretary Waterside Workers' Union to Mr. Dickson, M.P. 44. Letter—23rd September, 1912—Mrs. Nicol to Mr. Bradney, M.P. 45. Letter—l2th September, 1912—from Mrs. Nicol to Mr. Bradney, M.P. 46. Letter —sth August, 1912 —from Inspector-General Hospitals to Hon. Minister, with InspectorGeneral's report annexed. 47. Letter —25th September, 1912—Secretary Auckland Timber-workers' Industrial Union to T. Chamberlain. 48. Letter—7th July, 1910— District Health Officer to Dr. Inglis. 49. Letter —sth July, 1910 —Dr. Inglis to District Health Officer, with notice re Mrs. Marsh. 50. Copies of two prescriptions (27/8/12 and 2/9/12) by Dr. Inglis for Mrs. Chamberlain-—Chemist Eccles. 51. Copy case-book, Mrs. Laura Chamberlain's case, No. 1325. 52. Copy case-book, Mrs. Martha Porch's case, No. 1338. 53. Copy case-book, Mrs. Laetitia Marsh's case, No. 800. 54. Notes of interview on 27th November, 1912, between Mrs. Nicol and Secretary Auckland Waterside Workers' Union and Hon. Minister, with copy of Mr. Chamberlain's statement, &c. annexed. 55. Form of actual or suspected infectious disease.

99

H.—3lb

Nos. 56. Inspector-General's Report (4/10/12) to Hon. Minister re Mrs. Chamberlain's case, with letter annexed (3/10/12) Inspector-General to Hon. Minister, and letter from Mr. Bradney, M.P., to Mrs. Nicol, dated 3rd October, 1912. 57. Notice from Dr. Inglis to Health Department, 6th September, 1912, re Mrs. Porch, and Inspector's (District Health Department) report annexed, dated 10/9/12. 58. Notice from Dr. Inglis to District Health Officer, 28th August, 1912 (received by District Health Department, 9th September, 1912), re Mrs. Chamberlain, and Inspector's (District Health Department) report 10/9/12 annexed. 59. Death certificate —10th September, 1912 —by Dr. Inglis re Mrs. Chamberlain (1) puerperal septicaemia and (2) heart-failure. Time from attack to death, twenty days. 60. Record showing rises of temperature, &c, 1908-12. 61. Statistics St. Helens Hospital, 1906 to 1913 — -(a) Indoor cases; (b) outdoor cases; (c) patients transferred to General Hospital, 1906-10, and from 1910-13 ; (d) deaths, 1906-10 ; (c) septic cases. 1906-13 ; (/) sutures, 1911-12. 62. The Midwives Act, 1908 (consolidation), No. 118, and repealing Act of 1904, No. 31. 63. The Nurses' Registration Act, 1908 (consolidation) No. 134, and repealing the Act of 1901, No. 12. 64. Regulations, 17th April, 1905 (Gazette, 27th April, 1905, page 1022) made under the Midwives Act. (Note. —These are apparently the only regulations which have been properly made by the Governor by Order in Council and gazetted under the Act.) 65. Rules (1911) for the Management of State Maternity Hospitals established under the Midwives Act. (Note. —These rules have not the effect or legal force of regulations made and gazetted under the Act. They were not made by the Governor by Order in Council and gazetted. See section 19 of the Midwives Act—Exhibit No. 62.) 66. Rules (1911) for the Guidance of Midwives. (Note. —These rules were not made by the Governor by Order in Council and gazetted.) 67. Williams on Obstetrics (1908 cd.), pp. 878-9, top page 881, 884-5, and 890. 68. Edgar on Obstetrics (1903 cd.) pp. 756-762, 777 et seq. 69. | 69a. -Three case-books —St. Helens. 69b. ) 70. Admissions by Mr. Mays, counsel for Department of Hospitals and St. Helens staff re Mrs. Chamberlain's treatment, &c, dated 16th January, 1913. 71. Letter dated 26th January, 1913, from W. O. Stevenson to Commissioner. 72. Bundle of temperature-charts. '.73. Letter (anonymous) 20th March, 1913, to Commissioner from " A Mother."

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ALPHABETICAL LIST OF NAMES OF WITNESSES (With Page Number on which Evidence appears). PAGE Abbott, William Norman . . .. .. . . .. .. .. .. 72 Adams, Charlotte Ellen Josephine .. .. . . . . .. .. .. 83 Allen, Angelina .. . . . . .. . . .. .. .. . . 30 Bowry, Marion .. . . .. . . . . . . .. .. .. 30 Briffault, Robert .. .. .. .. .. .. ...' .. ..39 Broadley, Martha . . .. .. . . .. .. .. .. 41, 70, 73, 79 Brockway, Walter Scott .. .. .. .. .. .. .. .. 26 Bryant, Hilda .. .. .. .. .. .. .. '.. .. .. 44 Burns, Jessie . . . . .. . . .. .. .. .. .. 88 Carmody, Bridget .. .. .. .. .. .. .. .. .. 73 Chamberlain, Thomas . . .. .. .. .. . . .. .. 21 Davis, Mabel .. .. .. .. .. .. .. .. .. .. 94 Endletsberger, Theodore . . .. . . ... .. .. .. .. 61 Finer, Sadie . . . . .. .. .. ... .. .. 25Frost, Constance Helen . . .. .. .. .. .. .. 89 Goldstein, Herbert Myer . . .. .. .. .. .. .. 35, 53, 57 Grieve, Robert . . .. .. .. . . .. .. .. 86 Hooker, James White . . .. . . .. , . .. .. ~ .. 33 Hooker, Minnie .. .. .. .. .. .. .. .. . . 28 Hunt, Louisa . . .. .. .. .. .. .. .. .. .. 25 Inglis, Tracy Russell .. .. .. .. .. 30, 33, 34, 35, 42, 45, 59, 69, 71, 95 Jakeman, Ethel Dora .. . . .. .. . . .. .. .. .. 94 Jones, Hannah .. .. . . .. .. . . .... 68 Keller, Florence .. . . .. .. .. .. .. .. 28, 35, 92 Lewis, Thomas Hope .. .. .. .. .. .. .. .. .. 86 Lindsay, Peter Alexander .. . . .. .. .. .. .. 61 Little, Cornelius .. .. .. .. .. .. .. .. .. 95 Ludwig, Charlotte .. .. .. .. .. .. 33, 36, 56, 63, 66, 72, 84 Maclean, Hester . . . . .. .. .. .. .. .. 75, 76 McDougall, Neil .. .. .. .. .. .. .. .. .. 74 McDowell, William CMsholm Wilson .. .. .. .. ..93 Maguire, Charles Evans . . .. .. . . .. .. .. .. 89 Makgill, Robert Haldane .. .. .. .. .. .. .. .. 85 Newcomb, Sabina . . .. . . .. .. .. .. .. 39 Porch, Martha .. .. . . .. . . . . .. .. . . 58 Porch, Norman Albert .. . . . . . . . . .. .. .. 38 Savage, Thomas Copeland .. . . . . .. .. .. .. 90 Schofield, Henry .. .. . . .. .. . . .. .. .. 76 Stevenson, William Oliver .. . . . . .. .. .. .. .. 74 Thomas, Ebenezer Joseph . . .. .. .. .. - - - - 56, 81 Thompson, Isabella .. .. .. .. .. - - - - - • .. 42 Underwood, Kate Annie . . .. .. . - - - - - - - 28 Valintine, Thomas Harcourt Ambrose .. .. ... .. .. .- 79,81 Way, Susie .. .. . . .. - - - - - - - - - - - - 70 Williams, Frances .. .'. .. .. .. .. .. .. ..27

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