H.—3lA

It is appropriate here, when the question of sufficient accommodation is under discussion, t® emphasize the fact that in New Zealand the possibilities for home treatment are extraordinary as compared with other countries. The standard of medical education is high. The financial resources of individuals are greater than those of persons in the same social grade in other countries. The less-well-endowed people generally are provident, and insure against ill-health by joining friendly societies. It is true that there is always a substratum of indigent persons, and that the disease is particularly rife among these, but this class is incomparably smaller than in other countries. There is no stint of good food. Climatic conditions are favourable, and the country affords a wide range. In every country the majority of patients will always be treated at home, for it would be impossible to erect sanatoria for all of them. In this country at present most cases are treated at home, and successfully treated. Sanatorium treatment is not essential for the cure of the disease. "It can be stated without fear of meeting proofs to the contrary that, on the whole, sanatoria do not show better lasting results than properly conducted home treatment " (Fishberg).* There will always be a large number of patients who prefer home treatment, and there are many who for temperamental and other reasons will not respond so well to treatment in sanatoria as they do at home. Eminent authority is divided in opinion on the value of sanatorium treatment, and also as to the proper function of a sanatorium. That a large number of patients do well in sanatorium is unquestionable, but doubt is expressed by some authorities whether they do better than under home treatment. These considerations have an important bearing upon the question of sanatorium accommodation, but do not touch the problem of the chronic case. As stated, sanatorium accommodation is adequate, except in the case of Otaki. Chronic-hospital accommodation is inadequate, and should be provided either in suitable annexes to the general hospitals, which is to be preferred, or by the building of special hospitals. To provide for chronic cases is a step in the direction of prevention, which is always better than cure. SECTION IV. Question 4. Whether the sanatoria, hospitals, and other institutions are being used to the best advantage. Legitimately quite different opinions may be held, and are held the world over, as to how sanatoria should be used. In the early days of the sanatorium movement it was supposed that sanatoria would be filled with incipient, ambulant cases and that all that was necessary in the way of construction was an open-air shelter, with no provision for warmth or nursing. As more importance was attached to climatic influence then than is the case to-day, these institutions were placed in districts, often remote, where the climate was held to bo favourable. As experience in the last twenty-five years has shown that a large number of more advanced cases benefit from sanatorium treatment, ideas have changed, and the modern view is that a sanatorium should be planned to receive and treat all classes of cases, and, as accessibility is regarded as of more importance thafi climate, the modern sanatoria are placed not far from centres of population. For admission to the modern American sanatorium " patients are grouped broadly into three classes —infirmary cases, semi-ambulant cases, and ambulant cases " —and the bed accommodation allotted to each class is " 40 per cent, infirmary beds, 35 per cent, modified infirmary type, and 25 per cent, for ambulant cases."f In New Zealand, where the budget for health purposes is not great, sanatorium-construction has not been able to follow pari passu the change in opinion. As a result most of our sanatoria are placed at considerable distances from centres of population, and in construction some of them (Cashmere, Upper Sanatorium, and Pleasant Valley) have not advanced beyond the early shelter-aggregate plan. Two of them, Otaki and Waipiata, show advancement in planning, but only Pukeora approaches what is now regarded as the best type of sanatorium building. But we must take things as we find them, and ask, " Are the institutions we have at command being used in the best interests of the tuberculous patients in this country ?" Before attempting an answer it is necessary to point out that in New Zealand the advanced chronic case is not regarded as a suitable inmate for our sanatoria. These cases are accommodated in special hospitals in the larger towns or in annexes attached to hospitals in country districts. They require nursing care and hospital comforts that our sanatoria cannot supply, and it is desirable that they should be within easy reach of their relatives. For the treatment of all cases of pulmonary tuberculosis other than the advanced chronic bedridden case the sanatoria are supposed to be available. They must be available if the best interests of tuberculous patients is to be served. If any sanatorium is not admitting all patients other than the advanced chronic cases, that sanatorium is not being used to the best advantage of the tuberculous patients in this country. The class of cases in any of our sanatoria is regulated by the persons who select the cases for admission. In the North Island the Superintendents of the sanatoria have practically no say in selecting the patients for their institutions. They do not see them before admission. The selection is done largely by the tuberculosis officers attached to the Auckland and Wellington Hospital Boards, and by the medical officers in charge of patients in annexes ; but general practitioners in country districts are at liberty to send cases in. In the South Island selection is made by the Medical Superintendent of each sanatorium. He, and he alone, is responsible for the class of cases in his institution. In making their inspection the members of the Committee saw every patient in the sanatoria individually. In every case the records were examined, and in most cases X-ray films were inspected. The patients were not examined physically. As regards the class of cases undergoing

* Fishberg : " Pulmonary Tuberculosis," 3rd ed., p. 726. t " Transactions of the American Hospital Association," vol. 29, p. 341 ; 1927.

3—H. 31A.

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