H.—3lb.

40

B. BBIFFAULT.

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