H.—3la

treatment in each sanatorium the result of the inspection was arresting. It was possible to classify the sanatoria sharply into two groups. In the first group —represented by the Middle Sanatorium, Cashmere, and Waipiata Sanatorium—the cases were almost all of the very early, minimal, type. The Director of Cashmere claims a recovery (" disease arrested ") rate of 98 per cent., and states that he has had only one recurrence in ten years, and that a doubtful case. No more eloquent testimony could be adduced in support of the statement that the cases admitted are all of a very early type. At Waipiata only four of eighty-four patients in the sanatorium had ever been proved to have had tuberculous sputum. A large majority of the patients had neither cough, sputum, nor constitutional symptoms, not had these symptoms been present since admission. The charts showed that a rise of temperature rarely occurred. Clearly, the cases were of a minimal type. In the second group — represented by Pleasant Valley, Upper Sanatorium, Otaki, and Pukeora—every class of tuberculous patient (jf we include one or two advanced chronic cases in Pleasant Valley and twenty-four advanced cases in the Upper Sanatorium) was undergoing treatment. Most of the cases were of the moderately advanced type and there were relatively few very early cases. In the Cashmere and Waipiata sanatoria the patients were very largely of a class that can be treated successfully at home if their home conditions permit. The possibilities of home treatment have been discussed in Section 111. Cashmere and Waipiata sanatoria are not strictly comparable as regards suitability of accommodation. Waipiata is more suitable for the admission of moderately advanced cases than Cashmere Sanatorium ; but the Director of Cashmere has this advantage over his colleague —he has Coronation Hospital near at hand. As he controls both institutions and can transfer patients from one to the other as he sees fit, they really comprise one sanatorium, Coronation Hospital serving as the hospital block. To this hospital he is able to admit moderately advanced cases ; but, nevertheless, the proportion of minimal cases in the whole sanatorium is too high. The Director is doubtless influenced in his selection of cases by the unsuitability of the accommodation in Cashmere Sanatorium for moderately advanced cases ; but in Pleasant Valley the accommodation is even less suitable, and yet good work is being done there with moderately advanced cases. Waipiata Sanatorium is the only distinct institution serving a country district of 212,000, with no large centres. All tuberculous patients other than advanced chronic cases in this district look to this institution for assistance. All have an equal right to enjoy its benefits ; but inspection reveals that admission is restricted to incipient, minimal cases, and to those of the more advanced cases that have demonstrated their ability to improve while living in the annexes to the district hospitals, where, as the Superintendent states, treatment is unsatisfactory. Some of these patients go downhill while waiting, some die ; while the earlier cases selected, who also have to wait, often recover before their time for admission comes. A return handed in at Timaru by tiie representative of the Hospital Board states that " During the past eighteen months thirteen patients selected as suitable for admission to Waipiata did not enter the Sanatorium for the following reasons : Seven refused to go, as patients stated health had improved ; two refused to go —no reason given ; two failed to make application ; one died while waiting ; one. could not go owing to business ties." It is probable that the twelve patients in the list who failed to avail themselves of the opportunity of entering the sanatorium were so slightly affected that they need not have been selected unless home treatment were out of the question. Had they entered the sanatorium when their turn came, although they had by then in all probability recovered, they would have been detained there for many months. That one patient died whilst waiting is a reflection upon a system of selection that denies a chance to a deserving case until it has proved itself capable of improvement. It is possible that the Medical Superintendent is influenced in his selection of cases by the facts that he has no infirmary block and that the winter weather at Waipiata is rigorous. But his sanatorium is, in construction, more suitable for the admission of moderately advanced cases than is Pleasant Valley, and the rigour of the winter weather might be met by the installation of central heating. He should be influenced rather by the reflection that his is the only institution in the district where, on his own showing, treatment for these cases can be carried out satisfactorily. At this sanatorium the records were meagre and not sufficiently informative, and compared unfavourably with those seen in other institutions. In fairness to the Superintendent, it should be stated that he is absent from the institution, visiting the district on twelve days in each month. If this leaves him insufficient time to make records he should be provided with an assistant, for the work of an institution is mirrored in its records and must be judged by them. Cashmere and Waipiata sanatoria, despite the fact that the cases admitted are of a type allowing of earlier discharge than is possible in the case of the more advanced disease treated in other sanatoria, have each a list of patients awaiting admission. Cashmere has a waiting-list of thirteen patients ; the first on the list has been waiting three months. Waipiata has a waiting-list of seventy-four patients ; the first on the list has been waiting many months. Inspection revealed another striking fact by which the sanatoria could again be classified into the same two groups. In Cashmere and Waipiata tuberculin injections are given as a routine treatment to every patient who can tolerate it. As only very early cases can undergo this treatment, practically every patient in these institutions is subjected to a course. In Waipiata the duration of the course is seven months, provided that delay does not occur by the patient showing a reaction as the doses increase. If this occur the course takes longer. The course is not begun until after the preliminary rest, followed by a full course of graduated exercises. The Superintendent attaches so much importance to this treatment that in order to complete the course he retains patients three or four months longer than he otherwise considers necessary. He states that his purpose in using tuberculin is to immunize the patient and so insure him against reinfection. It is neither the function nor the desire of this Committee to condescend upon details of treatment, except in so far as they may appear to impair the usefulness of the sanatoria ; but, as the use

18