PUBLIC HEALTH AND HOSPITALS AND CHARITABLE AID: REPORT THEREON BY THE INSPECTOR-GENERAL OF HOSPITALS AND CHARITABLE INSTITUTIONS AND CHIEF HEALTH OFFICER.

Appendix to the Journals of the House of Representatives, 1917 Session I, H-31

H.—3l

1917. NEW ZEALAND.

PUBLIC HEALTH AND HOSPITALS AND CHARITABLE AID: REPORT THEREON BY THE INSPECTOR-GENERAL OF HOSPITALS AND CHARITABLE INSTITUTIONS AND CHIEF HEALTH OFFICER.

Presented, in pursuance of Section 76 of the Hospitals and Charitable Institutions Act, 1909.

RE POET. The Inspector-General of Hospitals to the Hon. Minister of Public Health. Department of Public Health, Hospitals, and Charitable Aid, Sir,— Wellington, 30th July, 1917. I have the honour to lay bef'ure you the report of the Department for the year ending 31st March, 1917. Though less eventful so far as the Department is concerned than the year 1915-16, the year just closed has been an exceedingly busy one, notably in connection with the accommodation and treatment of our sick and wounded soldiers. Fortunately there has been very little trouble as regards the arrangements for those of our countrymen who have fought in this world-wide struggle, and this reflects great credit on Dr. Frengley and his staff and the Medical Superintendents of our institutions, who have worked splendidly, though often at great disadvantages as regards their medical and nursing staffs, which have been considerably depleted. In this connection I cannot refrain from referring to the great loss the Department has sustained by the death of the late Lieut.-Colonel Hope Lewis, whose zeal, energy, and devotion to duty had so largely contributed to the success which had attended the "boarding" and treatment of our military patients. The shortage of medical men, especially as regards our public institutions, has become very acute, and is likely to become more so if the war continues much longer. It is to be hoped that as a result of the conference between representatives of the British .Medical Association and yourself measures may be brought down with a view to supplying sufficient medical men for the Expeditionary Force and home service without ignoring the wants of the civil population. Nevertheless the public—bearing in mind the great issues at stake—must be prepared to make some sacrifices and to put up with some inconvenience as regards the medical service of the country. Artificial Limbs for Returned Soldiers, Cabinet having recently decided that this Department was to undertake the management of the manufacturing of artificial limbs, premises were accordingly obtained at the Public Works shops, where two returned soldiers who had special experience in the manufacture of artificial limbs at the Roehampton Hospital are now engaged, and have already effected repairs for some of our maimed soldiers. In all possibility it may be necessary to extend this workshop, and it is hoped that as there are several New Zealand soldiers who have lost limbs now being taught at Roehampton their services will be available for the factory on their return to New Zealand. Infectious Diseases. Unfortunately there has been a considerable.increase in the number of cases of infectious diseases notified, especially as regards scarlet fever and diphtheria. Of the former no fewer

fl.-—3l

2

than 4,278 cases were notified, an increase of 1,977 over the previous year. Of diphtheria, 2,376 cases were notified, being an increase of 972 cases as compared with the preceding year. Fortunately there was a decrease in the number of notifications of tubercular diseases (950), and also a decrease of 14 in the number of notifications of enteric fever (806). The year was also an unfortunate one as regards the epidemic of infantile paralysis, no less than 1,018 cases being reported, as follows: From the Auckland Provincial District, 546; Wellington, .382; Canterbury, 65; and Otago, 25. The special report by Dr. Sydney Smith on this subject has already been laid before you, but reference might well be made again to the good work performed by Nurse Bevilaqua and her assistant Miss Gully, who were brought over from Australia so that the experience they had received there under Dr. McKenzie might be used to the advantage of the patients suffering from this disease in the Dominion. It is early yet to judge the results attained by their ministrations, but from reports received it would appear that extraordinarily good results were achieved, and that many a child who might otherwise have been a permanent cripple has been able to regain the full use of its limbs. In the course of the ensuing year it is hoped that a full report as to the results attained by Nurse Bevilaqua's treatment will be laid before you. In connection with this matter I am' glad that you have determined to send two New Zealand nurses to Manchester, so that they will be able to acquaint themselves with the methods adopted by Sir Alfred Jones in the treatment of this disease, and on their return to the Dominion be competent to assist the afflicted, and train other nurses in the special methods they have learned. I would refer you to an appendix to this report, prepared by the Government Statistician, showing the number of deaths from the various infectious diseases, and also the number of deaths of children under one year. Reference may also be made to an appendix to this report showing the number of infectious-disease cases notified in the Dominion. Cerebrospinal Meningitis. —During the year 135 cases of this disease were notified, an increase of 50 over the previous year. There were 54 deaths from this disease. Where cases of this disease have occurred amongst civilians strict inquiries have been made into all the circumstances and steps taken to prevent the spread of the disease. Consumption. —ln several reports reference has been made to the large number of cases of this disease occurring amongst members of the Expeditionary Force. Up to date no fewer than 261 cases have been reported. 281 cases were also notified by the Medical Boards. These figures show the necessity for increasing the accommodation for consumptives in the Dominion, and I have no doubt that it will before long be necessary to erect an additional sanatorium for consumptives irf the North Island. The institution at Cambridge is capable at the utmost of accommodating 100 patients, though considerable improvements will have to be effected there before it can be said to be thoroughly equipped in every particular for the treatment of this disease. Your recent decision that this institution should bo reserved entirely for male patients is a very excellent one, and as time goes on it may be possible to so improve this Sanatorium that in can with some degree of confidence be compared with similar institutions in Otaki and Christchurch. But owing to the configuration of the land, its situation, and its distance from the town it will never be possible to administer this place as efficiently and as economically as institutions of a similar nature more favourably situated. With the erection of a new institution that does not suffer from the disadvantages that Te Waikato labours under it might be possible to divert the land now attached to it to some other useful purpose. It is also fortunate that you decided to take over the Sanatorium at Otaki from the Wellington Hospital Board. By this means matters as regards the admission of patients have been much simplified. It is proposed for the present to use Otaki for female patients only, but as time goes on it will be necessary to greatly increase the accommodation at this institution. It is indeed questionable if it would not be of great advantage to the community for the Government to take over all the existing consumptive sanatoria. There is no doubt that there is much argument on the side of the administration of consumption being regarded as a national rather than a local responsibility. Dangerous Infectious Diseases. Smallpox. —There were two cases of smallpox on the transport " Willochra," which arrived at Port Chalmers on the 13th May, 1916. The vessel was accordingly placed in quarantine and all persons on board sent to the Quarantine Island and retained sixteen days, those who did not show signs of recent vaccination being vaccinated. Two cases of the disease subsequently developed on the island, and of the total of four cases two proved fatal. I would call your attention to the District Health Officer's report thereon, which has again exemplified the protection afforded by vaccination. When it is considered that there were 303 persons on board the " Willochra," many of whom had never been vaccinated, or had only been vaccinated in infancy, and, further, that the means of isolation on board the vessel were by no means satisfactory, the protection afforded by vaccination on the vessel after the outbreak is very striking. It is on this account that I specially draw your attention to this report in the hope that it may induce parents and guardians to have their children vaccinated, for this is the only known means of protection against the grave and horrible disease. The latest reports of Vaccination Inspectors show that not 1 per cent, of the children born in the Dominion have been vaccinated, and though possibly a number of children were vaccinated and were not notified, yet undoubtedly a very large percentage of the children born in the Dominion are not vaccinated. The District Health Officer, Dunedin, Dr. M. H. Watt, reported as follows: — " Vaccination as a Protection against Smallpox. —The recent outbreak of smallpox on 'the ' Willochra ' again serves to illustrate very clearly the efficacy of successful vaccination in protecting, the individual against a most dreadful and loathsome disease. While the smallpox in the

H.—3l

3

Maori epidemic of 1912 was comparatively mild and innocuous, in this latter manifestation it had reverted to the type which long ago caused it to be regarded as one of the scourges of mankind. Out of a total of four cases from the ' Willochra ' two died, while a third was critically ill for several weeks, and then made a slow and tedious convalescence. These three cases were all of the type known as ' confluent,' and were characterized by a very extensive skin-eruption and a profound toxasmia. None of them had been successfully vaccinated at any time, either in childhood or in adult life, consequently the disease ran its ordinary severe course uninfluenced in any way. The fourth case, which shows up in marked contrast to the three just mentioned, was that of a man aged thirty, who had been successfully vaccinated as a child. He had a very mild attack of ' discrete' smallpox, the skin-eruption was not extensive, and his symptoms were few. He was feverish for only three days, and thereafter entered 011 his stage of convalescence, making a rapid and uneventful recovery. Here the effect of the old vaccination is noticeable, and while not altogether immune, owing to the time which had elapsed since the vaccination, yet he was afforded a very considerable degree of protection, and was affected by the disease in an appreciably modified form. "As evidence that vaccination affords absolute protection against smallpox is the fact that of the five people in constant attendance upon these patients not one acquired the disease, although living continually in an atmosphere and amongst surroundings which were absolutely impregnated with the contagion of the disease. These five people were all protected, one, it is interesting to note, by a former attack of smallpox when a child, the remaining four by recent successful vaccination. They adopted no special precautions to safeguard themselves, being confident that tliey were absolutely immune against the disease, and such proved to be the case. " These observations, then, confirm the claims that have been made in favour of vaccinaton " (1.) Recent successful vaccination is an absolute protection against smallpox. " (2.) Successful vaccination in the past will afford some degree of protection, depending on time which has elapsed since the vaccination was performed." Leprosy.—Of the three cases in quarantine at the commencement of the year the Maori case was discharged, having for two years been proved negative to the disease by bacteriological examination. He was allowed to return home, where he shortly afterwards died from natural causes. A case was admitted during the year, the patient being a returned soldier. The history of the case showed that in boyhood he was in India, and probably contracted the disease there. There is nothing special to report in regard to the condition of the other two cases. Maternity Hospitals. Attached is an excellent report by Miss Maclean, Assistant Inspector, 011 the above-mentioned hospitals and the administration of the Nurses and Midwives Acts. There is no doubt that as a result of the appalling wastage brought about by the war it will be necessary to afford every facility to mothers with a view to maintaining the population by liatural means. Several reports on this important matter have been submitted, and as a result all Hospital Boards have been circularized as to the necessity of erecting maternity wards in connection with their hospitals. By this means it may be possible to afford mothers all the advantages of modern treatment at a very much reduced cost. Already several Hospital Boards have intimated their decision to erect maternity wards at their hospitals at an early date. Napier has, through the generosity of Mr. L. H. McHardy, secured a building, which has been converted into a maternity home. A movement is also afoot in Hastings to provide a similar institution. Buildings for the same purpose have also been acquired in Invercargill and Blenheim. In the latter place an epidemic of puerperal septicaemia showed to the Board the necessity of providing such an institution. I am certain that it is only a question of time when all the country hospitals will be provided with suitable maternity wards, which will not only allow patients to be treated therein at a greatly reduced rate, but will also allow increased facilities for the training of midwives, for whom "there is a great want in the more remote country districts. Infantile Mortality. Without doubt every effort should be made in the direction of still further reducing the infantile-mortality rate, which has been very apparent during the last decade, and shown that the results of the efforts of the Plunket Society, the St. Helens Hospitals, and the Department have not been in vain. It is hoped that during the ensuing year special measures will be undertaken in this direction. Pre-natal clinics have been established at our St. Helens Hospitals with a view to encouraging expectant mothers to consult as regards their condition of health before confinement, and these clinics have been fairly well attended. Arrangements are also being made for nurses to visit the newly born so that the mother may receive the best of advice as regards the treatment of her infant. To this end also it is hoped that the district nursing scheme will be very much extended during the ensuing year. Private Hospitals. A summary of private hospitals appears as an appendix to this report. It will be noted that licenses have been given to 260 private hospitals, of which 165 are for maternity patients only. It is pleasant to note that some of these maternity hospitals encourage their patients to report from time to time on the progress made by the infants born in the institutions, thus following on the lines of our St. Helens Hospitals, where much good has been derived by these means.

H.—3l

4

Hospitals and Charitable Aid. I regret that 1 am unable to comment on the hospitals and charitable aid expenditure, as the full and correct returns from Hospital Boards have not yet been received. It is proposed that these returns, with comments thereon, be issued during the year as an appendix to this report. There are, however, one or two matters in connection with hospital administration that require serious and immediate consideration. Firstly, the 'sliding scale of subsidy provided for in the Act has been by no means the success that was anticipated, and in common fairness to the poorer Hospital Boards it is necessary to place the scale of subsidy on a more reasonable and practical basis. It is hoped that the scale of subsidy adopted when the Act first came into force would run in the direction of increased assistance for the poorer Hospital Boards, especially where the administration was efficient. Such, however, was not borne out, and the necessity for revising the form of subsidy will be palpable to any one who takes the slightest interest in the matter. Another question requiring attention is that of patients' fees. A perusal of hospital reports will show the diversity that exists in the various districts as regards the payment made by patients. Some Hospital Boards make every effort to obtain maintenance fees from those patients who arc in a position to pay, though 011 the other hand some Boards apparently make 110 effort in this direction. I consider that this should be taken into consideration when the amount of subsidy payable to a Hospital Board is decided upon. Nowadays a large number of patients who are able to pay full hospital fees are admitted to our public institutions, and there is not the slightest excuse for Hospital Boards who do not make every effort to collect the flees and thus increase this source of revenue. During the year the Department has circularized Boards with regard to the advisability of adopting a uniform maintenance fee for the whole of the Dominion, but little success attended the effort; nevertheless Hospital Boards have agreed to fall into line as regards the maintenance fees to be paid to each other, which certainly is a step in the right direction, as under the old system the differences in the rate occasioned much quarrelling amongst Boards. The Medical Practitioners Act, 1914. Three meetings of the Medical Board constituted under the above Act were held during the year, and granted registration to twenty-eight applicants. Amongst various matters dealt with steps were taken to purge the Medical Register of eighteen names of men who were either dead or had ceased to practice; four of these were reinstated. Sale op Food and Drugs Act. During the past year, in accordance with your instructions, attention was mor'e painstakingly given to the inspection and supply of articles of food most commonly consumed, with the following results : 1,802 analyses were made by the Department's analysts, of which 1,473 were milksamples. With regard tp bread, 2,281 samples were weighed, and of these 157 were shortweight. The total of tines and costs where legal proceedings resulted from sampling or weighing amounted to over £650 for the year. In May, 1916, there were gazetted regulations defining the term "whey butter," and setting out the method of labelling. The Department suspects that butter which properly should be labelled " whey butter " is being sold as ordinary butter. It' is difficult to locate actual fraud, nevertheless steps have been taken which it is hoped will either confirm or remove these suspicions. Quackery Prevention Act. A somewhat audacious attempt 011 the part of an Australian quack to sell a "cure-all " with the usual campaign of popular methods for the extortion of money from the credulous public was effectually suppressed under the above Act by the issue of notices to the principal newspapers circulating in the Dominion advising them that the claims for this cure-all Were false in the meaning of the Act. Further steps taken were the prevention of correspondence with the proprietor and the prevention of the importation of the articles sold by him. This successful effort will no doubt act as a deterrent to other persons with similar designs. Despite the difficulties experienced in dealing with these attempted frauds in other countries, it is hoped that further action under the Act will either effectually curtail the activities of these persons or at least demonstrate the direction in which further legislative action is needed. Plumbers Registration Act, 1912. The triennial election of the engineer, master and journeymen plumber members of the Board took place in May, 1916, and the former members —Messrs. W. H. Morton, J. S. Douglas, and J. Clark—were re-elected. Eleven meetings of the Plumbers' Board of New Zealand were held during the year. The Board held an examination under the Act in September, 1916. Seventy-two candidates presented themselves, the result being as follows : Twelve candidates qualified in the theoretical part, eight in the practical part, and twenty-nine qualified or completed in both parts of the examination, and were duly granted registration. In addition ten other plumbers were admitted to registration during the year under the other provisions of the Act. To date the names of 1,218 plumbers have been entered in the Register. Out of this total twenty-one names have been removed —twelve through death in civilian life and nine through death on active service. 981 pocket certificates of registration have been issued for the year 1917; 114 other registered persons have not applied for tickets for 1917.

H.—Bl

5

Staff.

t)uring tlie year I regret to report that the Department has lost the services of Dr. Sydney Smith, who accepted a position with the Egyptian Government. Dr. Watt succeeded Dr. Smith as District Health Officer at Wellington, and in this connection it may be said that Dr. Watt is the first New Zealand graduate to take service in this Department. I cannot conclude this report without thanking those officers of the Department who have so cheerfully and so ably assisted me during this distressful year. I have, &c., T. H. A. Valintine, Inspector-General of Hospitals and Chief Health Officer

VITAL STATISTICS. Infectious Disease. The following table shows the number of oases of infectious diseases notified throughout the Dominion throughout the year 1916 : —

Deaths of Children under One Year. —Census, 1916.

Deaths from Certain Infectious Diseases, 1916.

Number of Cases. Kate of Incidence per 10,000 of the Population Disease. j 7 ■ 1916. 1915. 1914. 1916. 1915. 1914. _ ~~ " j ~~ ~ Scarlet fever .. .. .. 4,278. 2,301 ! 1,506 39-45 20-91 13-81 Diphtheria .. .. .. 2,370 1,404 1,095 21-80 12-70 10-04 Enteric .. .. .. 800 820 859 7-42 7-45 7-88 Tuberculosis . . . . . . 950 1,001 957 8-73 9-10 8-78 Blood-poisoning .. .. 174 140 102 1-60 1-27 1-49 Chicken-pax .. .. . . .. 354 I , 123 . . 3-22 10-30 Smallpox .. . . .. .. I 03 . . .. 0-58 Polio-myelitis .. .. 1,018 ' 10 268 9-37 0-09 2-40 Cerebrospinal meningitis .. 135 85 .. 1-24 0-77 Hydatids .. .. .. 25 17 .. 0'23 0-15 Ophthalmia neonatorum* .. 17 .. .. 0*10 .. , Totals .. .. 9,778 0,133 6,033 90-00 55-72 55-34 * Not notifiable prior to 1916.

,, Number of | Percentage of Ua 86 Deaths, 1916. | Total, 1916. Whooping-cough .. .. .. .. 44 3-04 Convulsions .. .. .. .. .. 74 5-12 Bronchitis and-pneumonia .. .. .. 75 5-19 Diarrhcea and enteritis .. .. .. 641 11-34 Malformations .. . . . . .. 108 7-47 Premature birth .. .. .. .. 381 26-35 Congenital debility .. .. .. .. 215 14-87 Other causes .. .. .. .. 385 26-62 Total .. .. .. .. 1,446 100-00

I Number of Proportion per 10,000 Clauses. Deaths, 1916. of Mean Population, 19 J 6. Typhoid fever .. .. .. .. 37 0-34 Measles .. .. .. .. .. 93 0.85 Scarlet fever .. .. .. .. 52. 047 Whooping-cough .. .. .. .. 98 0-89 Diphtheria .. .. .. .. 163 1-48 Influenza .. .. .. .. 73 ! 0-66 Pulmonary tuberculosis .. .. .. 591 , 5-38 Other forms of tuberculosis .. .. 151 I I -37 I

H.— 81

6

THE NURSES REGISTRATION ACT, 1908; THE MIDWIVES ACT, 1908; AND PART 111, HOSPITALS AND CHARITABLE INSTITUTIONS ACT, 1908. Miss Maclean (Assistant Inspector and Deputy Registrar of Nurses and Midwives) reports as follows :— Nurses Registration Act. During the year 1916-17 two examinations were held by the State. 196 candidates sat for examination, of whom 166 were successful in passing, and tlieir names were placed on the register. Thirty-eight nurses were registered from overseas. No large contingents of nurses have left New Zealand for war service since last report, but some nurses have been sent with each reinforcement, and a contingent of twenty-five nurses was sent in response to a request from Headquarters, London, in January, 1917. There are now 430 nurses on the Army List, of whom thirteen have been enrolled in England, and it has been found necessary to have a Matron in charge of all these nurses at Headquarters, London. Miss Thurston, Matron of Christchuroli Hospital, who was on leave from that hospital in order to take charge of the Walton-on-Thames Hospital for New-Zealanders, was appointed to that position. All the New Zealand Army Nurses, many of whom for the first two years of the war worked under the War Office in Imperial hospitals and ships, have now been called to join their own service, and it is. unlikely that many more will be required to staff the New Zealand hospitals in England and France. The two hospital ships " Maheno " and " Marama " have been recommissioned. The Matron of the " Maheno " (second commission), Miss Bicknell, having returned to her work in this Department, Miss Bagley has taken her place with a fresh staff of sisters. The " Marama " staff, with Miss Brooke, first Matron of the " Maheno," was composed of some members of the first commission of the " Maheno," supplemented by newly enrolled sisters. The various military hospitals in the •Dominion have been staffed by returned sisters, and during the early part of the year, owing to sickness in the camps, absorbed also some private nurses. In the latter part of the year the work in these hospitals was greatly decreased. With regard to work in civil hospitals, the nursing staffs have been fairly adequate, and there has been less urgent call for staff nurses and sisters. The war has brought forward many young women of a desirable class for training as nurses who had otherwise not thought of this career. The tendency of the Hospital Boards to increase the salaries offered, and the many avenues of work now opening out before trained nurses, has also improved the future prospects of the profession. Owing to the shortage of medical practitioners, nurses have been called upon in country districts to do much on their own responsibility with regard to the treatment of the sick, which formerly lay outside the scope of their work. For this work it has, unfortunately, been very difficult to obtain suitable women, and many country districts are now without either doctor or nurse. Native Health Work and Maori Nurses.—The development of this work has been retarded through so many nurses being away on account of the war, and only two nurses have been appointed to this special work during the year. District Nurses. —During the last year in the hospital districts in remote parts it has been realized how valuable a service of district nurses, fully qualified in general and midwifery nursing, may be. Owing to the shortage of doctors there have been many calls for well-qualified and experienced nurses with which it lias been impossible to comply. Such nurses need experience beyond their ordinary training, and are very hard to find. After the war there will be many returning from active service with the requisite experience, and it is hoped to largely extend this branch of nursing-work. It will be necessary to make the position more attractive to nurses by offering larger salaries and by providing comfortable accommodation. Plunket Nurses.—This branch of Health work remains much as last year, with the addition of two nurses and the opening of two new branches at Masterton and Hamilton. To help the nurses established at Nelson and Wanganui and at Timaru, which are large districts, a liaritane babies' nurse has been posted as assistant to the Plunket Nurse. This word is also hampered by the scarcity of the right kind of fully qualified nurses, and during the war many nurses with midwifery training only have been appointed to positions. It is found that with the year's training at St. Helens or other maternity hospitals, and six months at Karitane, these nurses make excellent Plunket Nurses. Useful observations have been made by the nurses on the conditions of health and provision of maternity nursing in some of the country towns. The society is endeavouring to largely extend its activities and to appoint a well-qualiffed nurse to superintend the work generally. Midwives Act, 1908. During the year there have been two examinations of midwives. Sixty-six candidates sat for examination : sixty-two passed and are now registered. Fifteen were registered from overseas. The lack of a high standard of training under the Midwives Acts for England and Scotland points to the necessity of amendments to the New Zealand Act, which allows a too-open door for the admission of midwives to the register whose course of training is far below the standard imposed on the midwives trained in the Dominion and in Australia. This is an injustice to the New Zealand midwives, which should be rectified as soon as possible. When the Midwives

7

H.—3l

Act was first passed in 1904 it was, owing to the shortage of midwives, inadvisable to shut out any women from the register who could show even fairly satisfactory training, but with the ever-increasing number of pupils being turned out year by year from the State maternity and other training-schools this is no longer necessary. State Maternity Hospitals. In the St. Helens Hospitals, Auckland, Wellington, Christchurch, Dunedin, and Gisborne 1,072 cases were confined during the year. 1,046 children were born alive, and forty-four stillbirths. There were eight maternal deaths, and twenty-eight deaths of infants. There were also attended 519 outdoor cases : no deaths of mothers and no deaths of infants. Sixty-five pupils have been trained during the year, and sixty-one registered; forty-eight are now in training. A property was recently purchased in lnvercargill for the purpose of establishing a St. Helens Hospital for that district, and as soon as some necessary additions are made it will be opened. A property adjoining the St. Helens Hospital, Auckland, has been purchased, and this addition to the site will allow of the erection of a new hospital and the conversion of the present hospital into a nurses' home. The building of the new hospital at Christchurch, which was deferred on account of the war, is again under consideration. The present building is quite inadequate for the increasing work, and the lack of suitable accommodation for the nursing staff renders administration exceedingly difficult. The accommodation of the St, Helens Hospital in Dunedin, owing to the existence of the Medical School Maternity Hospital in the same town, has not been seriously overtaxed, but the institution is still greatly in need of improvement, especially in regard to convenient and suitable sanitary arrangements. A new hospital should be erected and the present building used as a nurses' home. In connection with the work of the St. Helens Hospitals, which is of so much value in the saving of maternal and infant life, an attempt has been made to extend the benefits of the hospitals to more than those who actually enter for treatment or are attended in their homes by St. Helens nurses. Arrangements were made during the year, and widely and continuously advertised, that advice would be given to expectant mothers at certain hours at the hospitals by the Medical Officers and trained staff. Circulars were sent to the members of the medical profession in all centres inviting them to send their patients to have those observations made regarding their state and fitness for the trial before them, which by timely treatment would save so many lives. It was recognized that frequently symptoms were overlooked by private practitioners owing to lack of time (especially during the war) and opportunity to observe their patients during pregnancy. Patients sent by doctors for such examination and advice were not to be treated as hosjiital patients, but to continue the patients of their private medical attendants. While these ante-natal clinics have been attended by a fair number of women, and undoubtedly some good has been accomplished, it is to be regretted that the medical profession has not taken advantage of this offer of help. It is intended during the forthcoming year to take other steps to spread the benefits of these State Maternity Hospitals throughout the Dominion, and Hospital Boards which have not already done so are also being encouraged to establish maternity wards in connection with the General Hospitals. The Wairau Board has already done so, and the Hawke's Bay Board is proceeding in this direction. Private Hospitals. There is not much to report concerning the private hospitals of the Dominion since last year. No new ones of any importance have been established. Some interesting returns have been obtained from those nurses, trained in St. Helens Hospitals, who have established private maternity hospitals. There are now thirty-five of these hospitals in centres and in country districts, conducted by nurses trained in the State Maternity Hospitals. Their average has been fifty-eight confinements per annum, and these range from 178 in one hospital to three and four in small ones which are not entirely for midwifery cases, and in the year 1915-16 there were 1,737 births in these hospitals. General inquiries as to the work of infant-life saving, apart from actual midwifery, elicited some interesting replies. Most of the nurses seem to have the opportunity of giving useful antenatal advice and securing medical treatment if necessary for their intending patients. This undoubtedly is one reason of the few serious cases and very few deaths in private maternity hospitals conducted by well-trained nurses, who quickly recognize the signs that, without treatment or early assistance in labour, would lead to trouble. The after-work of the nurses in connection with the babies born in their establishments is of great value in the saving of infant life, as the majority encourage the mothers to bring the babies periodically for advice regarding feeding and general treatment, or recommend them to get the Plunket nurses to give them the same advice. The chief bar to the success of these private maternity hospitals owned by nurses is the lack of capital to enable them to make a good start in building or renting suitable houses, in which the cost of adding necessary sanitary appliances is very high. The cost of living having gone up, the usual fee, three or four guineas, does not give much profit for the arduous work, often without sufficient help.

HL— 31

8

The competition of unqualified women, who to add to their husbands' earnings like to take in a few cases, is also a detriment to qualified maternity nurses settling in country districts. An amendment of the law allowing any one to receive one case at a time without a license is necessary to protect the interests of the trained midwife and ensure to the expectant mother, not always alive to her own interests, the best attention at this period so important to herself and her child. Reports show how appallingly ignorant many women are of what they need, and their willingness to pay for and put up with attendance and surroundings far from what they should have. To assist qualified midwives willing to start maternity homes in such country districts, Hospital Boards, and through them the Government, should be prepared to give subsidies when necessary. Massage. The Bill for registration of masseuses has not yet been made law, but the establishment of a recognized course of training by the Dunedin School of Massage is having the good effect of providing a number of well-trained masseuses and a few masseurs for the work of the Dominion. When the Bill does become law these will be ready for registration. A few of these trained masseuses have been taken on for service during the war on the hospital ships and at military hospitals. As more of our wounded and disabled soldiers return there will be much need for this branch of work.

Approximate Cost of Paper. —Preparation, not given ; printing (1,55(1 copies), £7 Ills.

Authority : MabCTJS F. Makks. Government Printer, Wellington.—l9l7

Price 6i1.~]