The Hospital Inquiry.

New Zealand Graphic, Volume XXXIII, Issue XXIV, 10 December 1904, Page 22

The Hospital Inquiry.

THE COMMISSIONERS’ REPORT.

WELLINGTON, this day. The Cabinet this morning had under its consideration the report of Hie Jtoyal Commission on the Auckland Hospital, which is as follows: — •'in the year 1901, prior to the appointment of Dr. Collins, the administration of the Hospital was left in the hands of Dr. Inglis and his subordinates, and of the Honorary Staff. Owing to certain newspaper agitation, the Hospital and Charitable Aid Board determined to make a change. The Honorary Staff pressed strongly for the retention of Dr. Inglis, at an increased salary, and for the appointment of a junior surgeon and physician in addition, all to be resident at the Hospital (and consequently to be singie men), the Honorary Stall continuing to perform all save the simplest operations, except in cases requiring instant assistance. This proposal the Board negatived, and an entirely new departure was taken by the appointment of Dr. Collins as Senior Mf.dic.il Officer. The intention of the Board was apparently to curtail as much as possible the work and responsibility of the Honorary Medical Stall’, and to place the Senior Medical Officer in a position unique in the history of any City Hospital in the colony. The effect of this has been to create friction between the Honorary Medical Staff on the one hand, and the Board and Senior Medical Officer on the other; has caused the resignation of many of the ablest men on the Honorary Staff; and has prevented others from applying for a position which is usually eagerly sought after by the first men in the profession. Since the appointment of Dr. Collins as Senior Medical Officer, in January, 1902, there appears to have been a steady deterioration in the surgical and medical work of the Hospital, to the manifest detriment of the patients. • The generally recognised interpretation of Rule 73 has resulted in all eases of fractures and dislocation being dealt with by and Under the direction of the Senior Medical Officer, and instances arc not infrequent where fractures have been set and attended to by the junior resident, with disastrous results. As examples of these results we cite the eases of Collioun, Allen, McLeod, and Peake (vide evidence pages .28(1, 441, and 256; also charges 21 and 19. mid i and 2, of "Additional Charges,’’ made by Dr. Neil in respect of these eases).

Collioun states that he shrived at the Hospital about midnight in some date in February, 1903, with a broken arm. There should have been three medical men on the premises, but none came to see him. His arm was fixed up by a nurse for the night. Next morning Dr. Collins and Dr. Williams examined him, wont aw ay, and left the two juniors. Dr. Horsfall and Dr. Bennett, to set it. They did so, and Dr. Horsfall attended to the arm until the bone had united. Then Dr. Collins examined the arm, and found it had to be broken again, and it was broken accordingly. William Allen arrived a* the Hospital with a broken arm on February 13th, 1903, at 10.15 a.m. He endeavoured io get a doctor, but none cam: 1 to examine him until 1.30. Then Dr. Collins examined the arm, and sent him upstairs to bed. The arm was set by flic two juniors. Drs. Horsfall am! Bennett. Ten days afterwards it nas "taken down"’ and reset by Dr. Horsfall, assisted by a uiir-e. This second setting was also n failure, and a photograph thereunto appended), taken by means of the X rays (Exhibit 0). shows the reason. Allen had to return to the Hospital, and then to undergo another operation. fils arm is nut strong row. John Donald McLeod was admitted into the Hospital on Saturday. the 20th February. 1904, suffering from a broken thigh. The accident happened nt Waipn on the IHtli February. The limb was temporarily dealt with by a Icea! doctor, who ordered him to the Hospital, lie was admitted between 5 and 6 o'clock in the evening, on Saturday, the 20th

February, and the limb was not attended to until the following Monday, wlien it was set by Dr. Bennett, one of the junior residents, who put on a Liston splint. The broken thigh was not examined by the Senior Medical Officer until a fortnight after the admission of the patient. From that period the fracture appears to have been properly attended to. The result of ‘.he case is that the fractured limb is crooked, and is one’inch and a half shorter than its fellow. The attached photograph snows the present condition of the limb (Exhibit L).

WILLIAM PEAKE’S CASE. William Peake was admitted into the Hospital on the 31st January, 1903 suffering from a fracture of both legs and a fractured jaw. The case was admittedly a serious one. The broken jaw, which appears to have given much trouble, was set by a junior resident (Dr, Horsfall), Hie Senior Medical Officer ordering the Charge Nurse of the ward to tell Dr. Horsfall to put the jaw in splints. The patient was in the Hospital for six months, when, being dissatisfied with his treatment, he left, and went into a private institution. He states that a short, time before leaxing the Hospital he was informed by the Senior Medical Officer that the fractured limb was uniting. and that he proposed to put Hie leg into plaster of Paris. On his entering a private hospital it was found necessary to remove a quantity of dead bone before the fracture eould possibly unite, ibis appears to be one of those eases where an immediate operation was absolutely necessary, and one in which every effort should have been made to procure the attendance of some member-or members of the Honorary ’ Staff to operate. We are by no means satisfied that sin h steps were taken. The opera--1 ion was performed by the Senior Medical Officer, assisted by the junior residents. Drs. Bennett and Horsfall. The case should, under the Rule 73, have been placed under the charge of the Honorary Staff. It. was a ease requiring serious operative interference, and as such the mile treatment, and responsibility did not under that rule rest with the Senior Medical Officer. The patient complained of (he food served to him, ami also states that the visits of the Senior Medical Officer were irregular and infrequent. It is perfectly clear to ns from the evidence that the operation for the 'removal of dead bone, which was performed at the private ’ hospital, should have been performed at the Public Hospital three months before the patient left it. THE WALLIS A. WHITE CASE. It is now our du’y to report cn a nv si serious charge against the Senior Medical Officer, Dr. Collins, ina.de r.sp. et.ing the treatment and subsequent d*ath of a patient named Wallis A. White. We find Hie facts proved before us to be the f l lowing:— On the 17th May last White was broiight to the Hospital dangerously ill. He was put to bed and examined by Drs. Collins and Neil. On bein' qn stior.e I he indicated the left side as Lie seat or pain, but Dr. Collins, in spite of n. lemonstrance from Dr. Neil, determined to perform the operatic n for appendicitis, in which the incision is made on t-.e light side. That in isien was made re ■ord 'n ’ ly, mill Hie ap.iemlix- was foii-d to I o n; rinal. Dr. Coiliusthen manipulated ih-i large intestine adjacent, to the -appendix. He found the intestine distended with, gas, ami certain foi’enl com retiem were also present. H" then mi'll- tw.i ine's ions in the bowel, the iijor im-isio'i was Hie smaller of the two. and w.is n >- pnri nt.ly made with a view of getting rid of the gas contained in the in’estin s. The lower incision was situated about, an inch and a half above the place where the appendix leaves the bowel, and f.om this orifice he , extracted two foeeai concretions each about the size of a walnut. He stated in his examination I ef< re Dr. MacGregor, that, these concretions were not sufficient io cause obs ruction of the bowel. After suturing these two inci-

sions; and the incision over the appendicular region, lie ma de'the median incision, in order to ascertain the position of any perforation that existed-the existence of a perforation somewhere being at that stage of the proceedings apparent. He also stated in bis examination befor< Dr. MacGregor, at the depar.mental inquiry, that he found the an.erior wall of the stomach very friable, and having three perforations in it, and that he had great difficulty in uniting them. The post mortem examination disclosed the fact that there was only on? perforated nicer in the duodenum. After suturing that uleer lie thin proeeided to }Mit a line of stitches or sutures in a portion of the stomach wall, where no ulcer existed; this line of sutures was situated near tlie small curiature of the stomach, and apparently the sutures included a portion of the snrill omentum. T'ue sutures were put in the stomach wall at a point where it was clearly proved no ulcer could have existed. Hie post-mortem examination showing that the stomach was an unu'eerated one, and that there was no evidence of any ulceration, except the one perforated uleer in the duodenum, which is not, strictly tp.mk'ng, a portion of the stomach. The medi m incision was then closed, and the patient carried upstairs to bed, after having been two hours on the operating table. He died two days afterwards. We are unanimously of opinion that the reliable evidence before as shows: — (I) Tnat the incision for appendicitis ought not to have been made; this,-however, is stated to have been a mistake which even a skilful surgeon might make. (2) Tint the two incisions in Hie int.< s’.Les i:e .r t'.’.o appendix were both > if t hem most dangerous and unnecessary. (3) That ths sutures above referred to put by Dr. Cellins in a stomach, which was proved to be an unnlcerated ene.-can- only be characterised as wanton and uncalled-for surgery, without any justification whatever, ancl that the. time taken up by that portion of the operation apparently lessened Hie patient’s chances of life. (4) That though the patient on his admission to the Hospital was in a very dangerous condition owing to the ptrf rat d uleer in the duodenum, he had a chance of life which was seriously diminished by the imiipractice of Dr. Collins. (5) That in order to conceal his malpractice, he falsely stated to Dr. MacGregor at the departmental inquiry that he found the antirior wall of the stomach- very friable, and having three perforations in it, and that he had-great difficulty in uniting them. Dr. Craig at the same inquiry stated that Dr. Collins “explored the siomach, wi ieh presented three ruptured ulcers, one of which was one and a half inches long, the edges were of such a friable nature that they could not hold the su'uris.” Dr. Parkes stated at the same inquiry: "Here in the stonmeh 1 saw two per forations (not three), the larger an opening at least au inch long.’ With statements of this iiatur-- b.fara us, we slmuld have felt great difficulty in arriving at any satisfact- ry eonelustcn. I ortunately-the exhumation, of ti e body of Mallis White was ordered by the Colonial Secretary. The post-mor eui w’as conducted by Drs. Savage and Bul ! , and the stomach and'intestines vr-re preserved and shown to us. Beth of these gentlemen gave. us. much vaha’de testimony, and their evidenc? eouph.’d . wi’li our own personal examination of the specimens enab’ed us to ,’u’g' of ths value of conflicting testimony in (his matter. The stomach and ine’s d intestines have been scaled up and diliv.r.d to the Inspector of Police. ETHEL MAUDE M.-INDOE. One of the charge.- marie against the Senior Medical'Officer was that he had performed the operation of hysterectomy upon Ethel Maud Mcfndoe. and that the operation was unnecessary and unjustifiable. A careful investigation of this charge showed that the operation was performed by Dr. Parkes, one of th i honorary, slalf, assiste:! l y Dr.' Collins. Tie' conclusion to which we ere*, led liy the expert iriedieal evideiire is that the diagnosis of the disease «a», under the extrn-.irdinarj ci iteuius lances surrounding I lie case, a rea.-onalde one, and that the bp oration Was justifiable, in addition to the cases above mentioned, numerous complaints were made against, the Senior Medical Officer as regards surgical practice. We do not consider it. is necessary to discuss t liese complaints in detail; some were apparently abandoned, as no evidence was led in respect of them, while others appeared, when investigated, to bo of little or uo importance. Those ccmplamta which re-

fer to the absence of the Senior Medical Officer from the Hospital,liis perfunctory attendance in the wards, and his aetrons as regards the lithological laboratory will be dealt with under the head of general ad ministration of the Hospital. CONSTITCTION OF THE BOARD. The Board is elected annually, and * continuous policy (so neccssarv to the proper management) is impossible. It is also complained that the Board is not a suitable body to manage a Hospital, as its functions include dealing with questions of charitable aid. This latter complaint can be met by the creation of the Hospital into a separate institution, in accordance with .Sections 42 and 43 of "The Hospital and Charitable Institutions Act, 1885.’’ To meet the first mentioned difficulty we suggest an alteration of the Statute whereby the Board in the first instance would be elected for three years, and thereafter a certain proportion of the members (say one-third) should retire annually, in rotation. It should consist of representatives elected by the local bodies and nominated by the Government, and provision should be made whereby there should always be at least one medical man on the Board. PRESENT CONDITION OF THE HOSPITAL BI’ILDINGS AND SUGGESTED improvements. The present condition of the Hospital buildings, both as regards Hie buildings themselves, with the exception of the Children’s Hospital and the Nurses’ Home, Is far from satisfactory. The main, or old, building consists of’a basement and two upper storeys. The basement is in a highly insanitary condition, cold, damp aiid cheerless. It is in this portion of the building that- Hie padded rooms, for what may lie termed semilunatics aiid delirium trenien’s cases, are situated. .1 be next floor, in which the first tier of wards - and the operating room are found, is entered by a double flight of stone stairs, up which all patients have cither to walk or be eair‘ed. The accident ward is on this floor. The large wards on each floor ar® in their construction, entirely out of date, and, as regards their construction, devoid of those safeguards which modern science considers of first importance, especially as regards surgical cases. Th« lavatories are in a very -insanitary condition, the bathrooms small, and inconveniently situated, an I the arrangements as regards privacy, both in the male and female lavatcries, are of the njost imperfect character. The opeiating room can only be regarded as a makeshift. It is a small room, lighted only from one end,. possessing none of those safeguards from septic which modern surgical science imperatively demands. There is no separate room in which to administer anaesthetics, no withdrawing or dressing-roinn for the surgeons. ‘The patient must be brought into the room-partially clothed, in full view’ of the surgccns surrounded by flic instruments which arc to be used upon his or Her body. In. short, the modern surgical requirements are conspicuous by their absence. There is no lift, and the patients have to be carried up cr down flights of steps, to and from the operating room. A large and up-to-date operating theatre is in course of construction as an adjunct to the Children’s Hospital, which has been constructed from the Costley bequest. This building, with its operating theatre, is situated about one hundred and -fifty yards from the main Hospital, and -between Hie Hospitals is situated an old wooden building known as the fever, or typhoid, wards. It is proposed to remove this, and to construct on or near its site new' and expensive surgical wards, connected by a covered corridor with the new operating theatre. It is absolutely necessary that either this should be done or a new and up-to-date operating theatre should be constructed in comiection with the arid building. The former course is, we consider, the best, as it would be nlnrast impossible to render any of the wards of Hie old buildings sufficiently aseptic for surgical work; it would be out-of the question to carry patients to and from ths old building to Hie new operating theatre for operation. Next to the Children's Hospital is the Nurses Home, and beyond that is the new building, intended for the residence of the Senior 'Medical Officer. This could no doubt be utilised in other directions. in another portion of the grounds are suitable buildings intended for possible srr.'ali-

pox and'plague’outbreak*. Webeg to ■strongly recommend that the alterations to the old niain Hospital building, urgently required, should be immediately undertaken, under the supervision of a competent architect, subject to the approval of the head of the Hospital Department. These alterations should, in our opinion, consist of;

1. A lift connecting all the floors of the Hospital with the basement. We are informed that a hand-lift, which could easily be manipulated, could be erected for from £2OO to £3OO. 2. The demolishing of the tower stairways, and the inclusion of the space so obtained in lavatories and bath-rooms. 3. The erection of an up-to-date operating theatre in connection with the main building, if the new surgical wards contemplated, and above referred to, are not at once erected; and 4. Some attempt to render more sanitary the main wards. In this connection we consider it is of the utmost importance that ail plans and proposals to improve the present building, or to erect new wards of any kind or description, should be referred to the Government Hospital Department for consideration and approval before the publie money is spent upon them. We consider that the spending of large sums of money by an annually elected Board, which can in the nature of things have no continuous policy, is vicious in the extreme, and is likely to result in the .waste of public funds. Under the Harbour Boards Act and tho Tramway and diher Acts, we find that before the expenditure of public money can take place, such expenditure must receive the consideration and sanction of Government departments, and we fail to see why the expenditure of public moneys in hospital improvements, half of which is contributed directly front the consolidated fund, should be exempted from this salutary check on expenditure. LUNATICS. " There appears to be great difficulty in dealing with cases of menial disease, whioh are just on the borderland of absolute insanity. In most- _ of such cases physicians will not certify that they are lunatics, and consequently they cannot be committed to an asylum; but their relatives or friends refuse, or are unable, to take charge of them, and bring them to the public hospital, where there is no proper accommodation for patients of this class. From the evidence before us, it appears that They are usually placed in the typhoid ward, and that persons suffering from delirium tremens are sent there also. The semi-lunatics are a source of constant disquiet to the fever patients, whom they occasionally attack, and the raving of a man in delirium tremens disturbs everyone in the building. ■We consider the practice of placing patients of either class among sufferers from typhoid is most reprehensible. At other central hospitals such patients are rarely admitted, and, if admitted, they arc sent elsewhere as early as possible. THE RELATIONS OF THE SENIOR MEDICAL OFFICER AND THE HONORARY STAFF. It is recognised as sound hospital practice, that the authority .of the honorary staff should be supreme in medical and surgical as distinguished from administrative matters. The resident officers are always in such matters subject to the honorary staff. This practice obtains, so far as we can learn, in all large hospitals throughout the colonies.- If, therefore, a departure is made from a practice so universal, it lies strongly on those making the change to justify it on substantial grounds. About two years ago such a departure was made. The Board, by Rule 37, constituted the Senior Medical Officer the medium of communication between the staff and the Board, and by another rule (No. 74) gave him the privilege of attending meetings of the honorary staff, whilst the Senior Medical Officer, by insidious methods, such as calling the staff to useless consultations, and minor operations, and appropriating to himself many of the major operations, on the plea of emergency, sought to make himself, and not the honorary staff, supreme in matters medical and surgical. The advantages of placing the honorary staff in the position of responsibility in these matters are: (1) The sick poor receive the benefit of best professional skill, and (2) the doctors in attendance have the advantage of the collective wisdom of their brethren on the staff. The disadvantage of placing tho Senior Medical Officer in supreme control is, judging by the present enquiry, that all difficult cases have a tendency to fall under the

-exclusive care of die resident, and such members only of the honorary staff as the former may choose to call to his assistance. One result of the change has been that the members of the honorary staff have not unreasonably been forced to the conclusion that they can only continue in office by sacrificing their selfrespect, and the majority of them have accordingly resigned. The reasons given by the Board for this departure from sound and recognised methods are of the flimsiest character, namely: (1) That it is improper that young and unmarried men. sueh as residents usually arc, should have the duty cast c.n them of attending married women; and (2) that complainti against the honorary staff have appeared in the leading and correspondence columns of the local press. The first of these reasons is so ludicrous that it only requires to be stated to make obvious the ground of its rejection; and as to the second, it docs not appear that proper investigations were ever made to discover that any justification existed. The Board would seem to have been satisfied with the mere making of the complaint, coupled with sueh imperfect knowledge as its members may have happened to possess. In all hospitals large enough to require an honorary staff, it should be insisted that the authority of that staff should be supreme in the beforementioned matters, and no departure from this policy should be possible without the concurrence of some central authority, preferably the Minister in charge, of the department. The present system under which a senior medical officer has supreme command of the Hospital having utterly failed, it appears to us advisable to recommend the adoption of that which is usual in most central hospitals, namely, the appointment of two junior surgeons and one physician, who should be unmarried, and should reside on the premises, and should be subject in all medical and surgical matters to the honorary staff. The latter should perform all important operations, saving only those of emergency, i.e., those that require instant treatment. The cost of this, we are informed, would be less than that of the disastrous arrangement now in force, and the ablest surgeons and physicians in Auckland, relieved from the incubus imposed upon them by the present rules, would not only be willing, but anxious, to serve on the honorary staff.

ALLEGED IRREGULAR ATTENDANCES OF THE SENIOR MEDICAL OFFICER. Tho fact that no provision was made at the Hospital for the residence of a medical officer, and that in consequence Dr. Collins resided at a distance from Urn institution, will fully account for these irregularities. AS TO MAJOR OPERATIONS. These operations are required to be performed l>y and to be under the control of the honorary surgeons, after consultation (sec Rules 21 and 36). Where the case is an urgent one, the Senior Medical Officer has a discretion to decide whether an immediate operation is necessary, but the ultimate responsibility' of the operation rests with the honorary surgeon, who takes charge immediately on his arrival (see Rule 72). An exception is made in tho ease of fractures and dislocations (Rule 73), but even in such cases, where the honorary surgeon expresses a wish to take charge of the case, or it is one requiring operative interference, responsibility' rests solely' with that official. There can be no doubt that the rules cited have been persistently misconstrued and ignored by the Senior Medical Officer, who has taken charge of cases which should have been dealt with by' the honorary staff. His conduct in this respect has had the tacit consent of the Board. BACTERIOLOGY. There is a skilled bacteriologist at tho hospital. Dr. Frost, and it appears that her work has been considerably interfered with by the Senior Medical Officer. We are of opinion that the culture by the latter of bacilli, and specially' of the anthrax bacillus, was fraught with danger to the patients whom he attended, and should have been most strictly' prohibited.

As an example rrf the interference of the Senior Medical Officer, we may adduce the ca"e of Miss Guthrie. It was suspected that she was suffering from tuberculosis, and Dr. Frost was requested to examine her sputum for (lie bacillus of that disease. She did so on ten different occasions, and the result was negative. Dr. Collins, however, gave it as his opin-

ion to the honorary staff that the bacillus was present, and a recommendation was consequently made with rrspset to the treatment of that patient which might have resulted in her being scut to the Sanatorium for C-onsumptives at Cambridge.

ADMISSION OF PATIENTS. The practice at present prevailing is not to admit any patient except in cases of accident, or palpably serious illness, without an order of admission obtained from some doctor. This practice, which was introduced at the request of the local contributing bodies, and is con.rary to rules 13, 140 and 141, has entailed needless suffering to patients who have presented themselves for admission. These have not infrequently been seen by a porter, and refused admission until the prescribed order was obtained. The applicant to procure this, has been compelled to travel some considerable distance in search of the Board’s dispenser, or some other doctor, to whom a fee would probably be payable for examination. We fail to sec why one of the resident staff (all of whom should never be absent from the Hospital at the same time) should not determine whether the proposed patient should or should not be admitted. FEES PAYABLE BY PATIENTS. By the 71st section of the Hospital and Charitable Institutions Act, 1885, the Board may claim from patients contributions according to their means. The primary intention of the Legislature is to make public Hospitals a place for the treatment of the sick poor, whilst not absolutely excluding the well-to-do. The practice of the Board has been to charge a fixed rate of 4/8 per day to rich and poor alike. This practice is in contravention of rules 142 and 143, as well as of the Statute. In the great majority of cases, however, the fixed rate has been either wholly or partially remitted. It cannot be said this is a compliance with either the Act or. the rules, because once it is established a patient can afford to pay the prescribed rate, he is liable for that rate, whatever his pecuniary position may be. It must be noted that repeated demands wire made for payment until the amount due is either - paid, or, on application to the Board, remitted. This practice had had a two-fold effect—first, it has tended to keep the deserving poor out of the Hospital, and has retarded the recovery of those who have entered, by reason of the moral compulsion to pay, which the fixed rate has imposed on this class. (2) It has encouraged a not inconsiderable number of well-to-do, who are about 20 per cent, of the total number of patients, to make use of the Hospital, to the occasional exclusion of the poor. The reason the well-to-do under present circumstances avail themselves of the Hospital is obvious— the charge made is not even an adequate return for the board, lodging, and nursing, whilst the services of the staff,.resident and honorary, inclusive of operations, arc obtained free. The proper course would be to let it be generally known that in deserving cases no charge whatever is made, and that when a charge is made, it is in accordance with a rate fixed with reference to the means of the patient. Under such. a rule the well-to-do would either be content to be treated in their own homes or they would seek the comparative seclusion of a private hospital. It must be here noted that whilst 20 per cent, of the patients admitted are of the well-to-do class, only seven per cent, of the total number admitted make any compensation to the Board. It thus appears that a certain proportion of those who are able to pay are not compelled to contribute anything towards the maintenance and medical attendance they have received in the Hospital. There is. thus, not only a loss to the Board, but the reception of so large a proportion of the well-to-do materially adds to the capital cost and upkeep of the institution. DISMISSAL OF DR. NEIL. Dr. Neil, it must be observed, was a member of the honorary staff, and the question whether this dismissal was justifiable depends on the further question whether Dr. Collins' method of operation in the case of Wallis White was in accordance with sound surgery. We have already reported it was not. No doubt the ground taken by the Board, after an inquiry had been held, was that Dr. Neil had approached it»

chairman (Mr. Garland) about the <aee. It was complained that the doctor had been absent from duty for seven days, without leave, in contravention of rule 12. These grounds of dismissal were merely ostensible. There is in evidence a statement by the chairman, made at a prior meeting of tho Board, that if he were a member next year he would do his duty and move a resolution in the direction of getting rid of the honorary staff, and it would seem from the manner in which the inquiry was conducted, and from the various reasons from time to time put forth by Mr. Garland for the dismissal, that it was determined on by the Board before ever- the inquiry was held. In our opinion the dismissal, assuming the Board hail power to dismiss, was without any justification. Taking the view that Dr. Neil did of Wallis White’s operation—a view which the evidence has borne out—it was not only the doctor’s privilege, but his duty, t > at once communicate with the chairman, and it must not be forgotten that the only justification fcr the Board's arriving at the conclusion that Dr- Neil was absent without leave was his omission to sign the honorary staff's attendance book, as required by rule 16, an omission which the doctor satisfactorily explained to the Board. FOOD SUPPLIED TO PATIENTS. A large number of the witness s having been patients in the Hospital, complained to us of the quality of the food supplied to them. They described the fish as frequently rotten, and served with the scales on, and the fowls served with feathers. Other patients, on the contrary, stated that the foed was all that could be desired. We do not expie s any definite opinion as to the quality of the food. Its inspection is, by Rulo 08, east on the Senior Medical Officer. This duty was relegated by him to the house steward. The matron of the Hospital should, we think, be charged with this duty. Her knowledge of the requirements of the different wards would, we conceive, < liable her to perform it satisfactorily, and. moreover, it appears to us to he much more the province of a woman than a man to superintend the distribute n of the food to the patients. HYPODERMIC INJEI TIONS. It was proved that in one ward the male nurse or wardsiuan was in the habit, of leaving open the < up' oard containing poisons dtii'ing his frequent absenc. s, and that it was a -common practice fcr one patient to administer hypodermic injections to others. Such dangerous carelessness deserves severe reprobation. OI'T-P AT IE N TS' DEI ’A RT M ENT. One of the complaints of the Auckland division of the New Zealand Branch of the British Medical Association is that there lias been a recurring tendency to the erection of an out patients' department in spite of the rules against it. There is no out-patient department in the Hospital itself. Rule 163 which deals with the matter, appears to be strictly followed. There is a pharmacy, which is situated about a m le from the Hospital, where persons of st.rr.ilen d means can attend and receive medical advice and medicine gratis. We llvnk Ihi * is a very satisfactory arrangement, and that no objection can possibly be t'lkin to it. THE MAINTENANCE OF CLINICAL RECORDS AND OTHER BOOKS OF RECORD CONNECTED Will I HIE HOSPITAL.

Wo find that most of the Hospital records and other documents produced to us in evidence were incorrectly and carelessly kept. The entries in the clinical record books wore of n most, perfunctory character. In many cases the result of treatment, is not, given, there being merely an entry of the mini? and disease from which the. patient win suffering. If operated upon, the word “Operation” appears, the effects of tho </>eratiou one is left to imagine. Tho best books kept in the. Hospital weru those produced by the nurses. We forward ns exhibits in this connection, three record books, namely, two ease books, marked respectively, 1. It. it. and 2. R. 8.. and also what appears to be an Vidmission book marked 3. R. B. Tho latter coiilrrns at page !) an entry of the admission of Wallis White on tho 18th May, 1904. case book 2, nt page 146 under date 17th May. 1901, shows an entry, “White, disease necrosis, operation.” There is no other entry in the name of White about that dale.