TUBERCULOSIS.

Otago Witness, Issue 3881, 31 July 1928, Page 17

TUBERCULOSIS.

COMMITTEE’S REPORT. CASHMERE AND WAIPIATA. VALUE OF TUBERCULIN QUESTIONED. WELLINGTON, July 27. Thirteen recommendations for coordinating the fight against tuberculosis in New Zealand are made by the Com mittee of Inquiry appointed by the Minister of Health (Mr J. A. Young) into the prevention and treatment of pulmonary tuberculosis in the Dominion. These pre as follows: — 1. A division for tuberculosis to be established in the Health Department under a director. 2. Hospital boards should be encouraged to establish tuberculosis dispensaries. 3. The 'routine use of tuberculin in panatoria should be discouraged. 4. Medical superintendents of sanatoria should be urged to admit all cases that would be likely to benefit. 5. The stay of minimal eases in sanatoria should not, as now, be unduly prolonged. 6. The accommodation at Otaki Sanatorium should be increased. 7. Extra accommodation should be provided for chronic cases in the special hospitals at Dunedin, Wellington, Christphurch, and Auckland. 8. Sufficient accommodation for tuberculosis cases should be reserved at the general hospitals in the centres mentioned for the benefit of patients, and to afford medical practitioners and medical Students opportunities for studying the disease.

9. The medical profession should be encouraged to co-operate with local authorities, the Health Department, and voluntary aid associations, in their efforts to ’ control the disease. 10., The Otago Hospital Board should be encouraged to join with the associated boards, to form one association. 11. The hospital boards in the South Island north of Ashburton should be encouraged to form an association with a committee representative of each district. 12. Specially trained nurses should be employed for the inspection of cases in homes.

13. The establishment of voluntary aid committees for discharged patients ami cases in homes should be encouraged. ■“ The investigation has shown the committee that pulmonary tuberculosis in New Zealand does not constitute a grave national menace. Fewer people die from all forms of tuberculosis than are killed by violence. So far as has been ascertained, the prevalence of pulmonary tuberculosis in the country is less than in any other' country. Substantial progress has been made in adopting measures for its control and treatment, but pulmonary tuberculosis is an insidious and protracted infective disease, which will gain ground and become a menace unless it is constantly repressed. The most important contribution that can be made to the successful issue of the ‘campaign is coordination of the measures and of the efforts now employed in fighting the disease.”

The above are the concluding remarks of the Committee of Inquiry, the report of whiph was presented to'Parliament today. The committee comprised Dr Frank Fitchett (chairman), Dr D. Eardley Fenwick, and Dr T. W. J. Johnson, and inquiries were made throughout the Dominion in terms of the wide order of reference of which the chief points were in respect of the insistent demands that had been, made for increased accommodation for the sufferers, the class of consumptive admitted to the sanatoria, in the Dominion,, the length of stay of the -patient at the sanatoria, and whether all the patients so admitted were suffering from tuberculosis in such a form as to render their prolonged stay necessary or desirable. INCIDENCE OF THE DISEASE. .

The report deals at length with the past and present incidence of pulmonary tuberculosis in New Zealand, and states that in the Dominion and other civilised countries the incidence, has declined steadily the past 50 or 60 years. The fall has been uninterrupted, and does not appear to have been influenced by any of the remedial measures introduced in the last 30 years for the direct treatment of the disease. The explanation usually given, the report notes, is that the decline has been brought about by education, by sanitary reform, and by an improvement in economic conditions. The increase in the notifications in the last three years is considered by the committee to be due probably to the greater activity of the various administrative bodies resulting in a higher proportion of cases being notified. It suggests that more reliable information is given by the death rate, which- is shown to have fallen from 9.70 per 10,000 of population in 1872 to 3.88 per 10,000 in 1927.

Reliable information concerning the incidence of the disease among the Maoris is not obtainable owing to the mass of the Maori.. population living in remote districts . inaccessible to doctors and inspectors, and because in many cases medical certification' of death is not made. The total incidence of. tuberculosis in 60,275 children examined by school medical officers in 1927 was 0.1 per cent., of which 0.04 per cent, was pulmonary, and 0.06. per cent, tuberculosis of tissues other than pulmonary. This percentage is in accordance with that found in previous years. ' — . “In view of the modern opinion that tuberculosis infection is most universal before adolescence,” the report states, “ it is probable that a percentage of' school children now classified by the school medical officers as. of subnormal nutrition has latent tuberculosis. In the annual report for 1927 the number -of New Zealand school children stowing evidence of subnormal nutrition is given as 7.14.” The report says that when notification is taken as the basis for estimating the incidence it shows that the incidence is greater in .Canterbury and Otago than in

Wellington and Auckland. This is because there are well-organised tuberculosis dispensaries in Christchurch and Dunedin, and as a result a more determined effort is made to seek cases out. If the more reliable death rate is taken as the basis for estimating (he incidence of the disease, the difference between the North and South Islands is shown to be negligible; and that while Otago shows the highest rate Conterbury shares with Auckland the lowest rate. A comparison of statistics' with oth.r countries shows New Zealand in a favourable position. Indeed, in no other country of the world for which reliable statistics are available, is the death rate so low. Figures given by the committee show that in 1926-27 the New Zealand death rate from all forms of tuberculosis was 5.13 per 10,000 cf population. Australia was next with 5.94; then Canada with 6.97; and then Denmark with 9.03. Hungary was the highest with 27.36 per 10,000 of population. QUESTION OF ACCOMMODATIQN. The committee deals with the measures taken for the prevention and treatment of tuberculosis in New Zealand, giving details of the accommodation available at each of the principal hospitals. Complimentary reference is made to the tuberculosis annexe in the grounds of the Waikato Hospital at Hamilton, which is completely self-contained, and might wel 1 serve as a model for future extensions to other hospitals. On the question ot accommodation the committee says there are several advanced cases in the Pleasant Valley Sanatorium that would be better placed at the Wakari chronic hospital. The evidence gives justification for the assumption that there are many advanced cases of patients lying in their homes in Dunedin who could probably be induced to enter Wakari Hospital. The committee is of opinion that the accommodation at this hospital is inadequate. The pressure at Pleasant Valley could be relieved by transferring some advanced cases to Wakari, were the accommodation available at the latter institution, and by discharging two cases of surgical tuberculosis. There is no need for the further extension of this institution or at Waipiata. At Timaru suitable -accommodation is at present inadequate, but the pressure could be relieved by expediting the admission of cases to Waipiata. - At the upper sanatorium at Cashmere there were 99 patients on the date of inspection. Of these, 24 are advanced cases and unsuitably placed. The accommodhtion of the sanatorium is adequate.

“ It is clear from the evidence,” the report says, “ that there is urgent need in Christchurch for further accommodation for advanced cases. The removal of 18 male patients from the Coronation Hospital is necessary to afford increased accommodation for female patients. Twenty-four advanced male cases should be removed from the upper sanatorium. The evidence tendered by representatives of the B.M.A. shows that there are a number of advanced cases in their own homes that should be in a chronic hospital.

In the Ewart Hospital at Wellington there are 45 cases. All the beds are occupied by cases of the advanced chronic type. The medical superintendent states that he is embarrassed by inadequate accommodation, and estimates that he requires twice as many beds as are now available. This hospital is now full, and is always full. In the general hospital there are 29 cases, and most of them are awaiting admission to the. Ewart Hospital, There are . four cases awaiting admission to the general hospital. The evidence by the representative of the B.M.A. goes to show that there are many advanced cases in Wellington lying in their own homes. It is clear that accommodation for chronic patients is inadequate. In the Costley Home in Auckland there were 68 beds for advanced cases, 66 being occupied. The medical superintendent stated that the accommodation was taxed to the uttermost, and that there was urgent need for more beds. There were cases in the Auckland Hospital awaiting admission, and many advanced cases tn their own homes. It was clear that the accommodation for., advanced cases in Auckland was inadequate.

It was found that there was difficulty and delay in getting natients admitted to the Otaki Sanatorium, and that patients were discharged earlier than was wise

in order to cope with the waiting list. There was adequate accomodation at the Pukeora Sanatorium. The conclusions of the committee under the heading of acccommodation are that there is sufficient accommodation in the North Island for males, but that more accommodation should be provided for females. In the South Island the accommodation for both sexes was adequate. It was found that the accommodation in New Zealand generally for chronic cases was inadequate and that extra provision was urgently required, particularly in Christchurch, Wellington, and Auckland. The committee adds that New Zealand affords more accommodation for tuberculosis cases than other countries and that the Dominion is the most favourably placed with 17 beds available for every 10 deaths. The committee emphasises that the possibilities for home treatment in New Zealand are extraordinary and that most cases are successfully treated at home. Sanatorium treatment is not essential for the cure of the disease. At the same time, however, while such considerations have an important bearing on sanatorium accommodation, they do not touch the problem of the chronic case. A CRITICAL SECTION. Discussing whether the best use is being made of the sanatoria, hospitals, and other institutions, the committee recites the change in ideas concerning the planning, structure, and location of sanatoria, and declares that if any sanatorium is not admitting all patients other than advanced chronic cases that sanatorium is not being used to the best advantage of the tuberculosis patients of the Dominion. It is shown that in the North Island the superintendents have practically ffio say in selecting the patients for their institutions, the selections being argely done by the tuberculosis officers attached to the Wellington and Auckland Hospital Boards, and by the medical officers in charge of patients in annexes, but general practitioners in country districts are at liberty to send in cases. In the South Island selection is made by the medical superintendent of each sanatorium. He, and he alone, is responsible for the class of case admitted.

“As regards the class of case undergoing treatment in each sanatorium, the result of the investigation of the patients and their records was arresting,” the port says. “It was possible to classify the sanatoria sharply into two groups. In the first group, represented by the middle sanatorium at Cashmere and the 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 10 years, and that was 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 84 patients had ever been proved to have had tuberculosis sputum. A large majority of the patients had neither cough sputum nor constitutional symptoms, nor 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 other sanatoria mo—were of the moderately advanced type, and there were relatively .... cases. In the Cashmere and Waipiata Sanatoria the patients were very largely of a class that could be treated successfully .at home if their home conditions permitted.- It was found that admission to Waipiata was restricted to incipient minimal cases ai.J to those of the piore advanced cases that’ have demonstrated their ability to improve while living in the annexes to the district hospitals. 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.

The committee is of opinion that the Cashmere and Waipiata Sanatoria are not oeing used to the best advantage. It reommends that the routine use of tuberculin be discouraged, and that Waipiata. Sanatorium be open' to all types of pulmonary tuberculosis that appear to offer a reasonable chance of benefiting by sanatorium treatment. The Wakari, Coronation, and Ewart Hospitals and the Costley Home for chronic cases are certainly used to the best advantage. The committee gives a special word to the Coronation Hospital, which, it says, is an admirably constructed and furnished annexe, the ad-

ministration of which leaves nothing to be desired. The annexes to the hospitals visited are also discharging their function staisfactorily. The Sunshine ward at Waikato and the annexe at Palmerston North are especially to be commended. The committee is of opinion that the general hospitals in the large cities are not being used to the best advantage of tuberculosis patients because no suitable accommodation is reserved for them There is a disinclination to admit this class of patients.

Discussing the use of tuberculin, the committee quotes authorities and states that its use as a therapeutic agent is of questionable value. The utility of the Waipiata and Cashmere Sanatoria is impaired by the routine use of this questionable agent. NEW HOSPITAL FOR CHRISTCHURCH.

The committee says it is clear that no extensive additions to existing institutions are necessary, but it is impressed by the evidence that many chronic open cases are living in their own homes, and by the observation that the provision made for these cases in institutions is not always suitable. It recommends the new chronic hospital of 40 beds for Christchurch as an urgent necessity, and that the demand for extra accommodation in Wellington and Auckland should be met. It is also suggested that the hospital boards in the chief centres might reasonably modify their policy with regard to the admission of tuberculosis cases, and that some accommodation should be specially reserved for these cases. The committee strongly recommends that additional accommodation for 20 patients should be provided at Otaki. k PREVENTION AND RESEARCH.

Dealing with preventive measures, the committee recommends the extension oF school medical inspection to high schools and the extension of health camps. It finds that the modern schools cf the Education Department appear to meet all requirements. There was a real need for accommodation homes for adult patients. The committee recommends that the Health Department should deal stringently with me.dical practitioners who neglect or decline to notify cases, and that the inspection should be done' by nurses rather than by men. The domiciliary inspection of discharged cases or known cases in homes should be extended, and after discharged the supervision should be undertaken by the tuberculosis dispensary or by a medical practitioner. It is suggested that voluntary care committees closely associated with the hospital boards should be established. These committees would make arrangements for the care of children in order to allow parents to undergo treatment in residential institutions; to . remove children from homes where the parents were in an infective condition; and to find work for patients on discharge. It is suggested that the committees should be left to' work largely on their own lines.

The encouragement co-ordination of research work is urged by the committee, which suggests- that this can be brought about by the appointment of a director of tuberculosis.' The committee considers that New Zealand offers great opportunities for research work that would be valuable not only to our own people, but to the world. It commends the pooling system of conducting sanatoria adopted by the associated boards in (the South Island. When the need for another sanatorium- arises in the North Island it should be located in the Auckland Province, and be supporteu by an association of the hospital boards of Southern Auckland, Bay of Plenty, Auckland. and North Auckland. The control of the present sanatoria might then pass from the Government to tie control of a committtee selected by the hospital boards, of the East Coast. Hawke’s Bay, Wellington Province, and Taranaki.

With reference to the South Island Association, the committee finds it difficult to understand why the. Otago Hospital Board should stand out from the'pooling scheme. It does not recommend one pool for the whole of the South Island, but suggests that it would be better if all the boards north of Ashbufton set up an association, with a representative committee to control the sanatorium at Cash-

With regard to the suggested director of tuberculosis, the committee says that his work should not be purely administrative. He should be in charge of a sanatorium, and have an office with an adequate clerical staff in the Health Department. In short,i his duties would be to co-ordinate the efforts being made to fight the disease. "