DEPARTMENT OF HEALTH. ANNUAL REPORT OF THE DIRECTOR-GENERAL OF HEALTH.

Appendix to the Journals of the House of Representatives, 1940 Session I, H-31

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1940. NEW ZEALAND.

DEPARTMENT OF HEALTH. ANNUAL REPORT OF THE DIRECTOR-GENERAL OF HEALTH.

Presented in pursuance of Section 100 of the Hospitals and Charitable Institutions Act, 1926.

HON. H. T. ARMSTRONG, MINISTER OF HEALTH. CONTENTS.

Reports of — hag is Director-General of Health .. .. .. .. • ■ • • • • • • • • 1-10 Director, Division of Public Hygiene .. .. .. .. •• .. .. .. 11-19 Director, Division of School Hygiene . . .. .. .. .. .. .. .. 20-24 Director, Division of Hospitals .. . . . • • ■ • ■ • • • • • • • • 25-27 Director, Division of Nursing ~ .. .. . • .. • • • • ■ • • - 28-32 Director of Maternal Welfare .. . . . . . ■ . • ■ • ■ • ■ ■ • • 33-43 Director, Division of Dental Hygiene .. . . .. .. .. •. .. • • 44-49 Appendix— A. Control of Diphtheria in a Rural Health District .. .. •. .. .. . ■ 50 B. Progress in Prevention of Typhoid Fever in Maoris .. .. .. .. .. 51 C. Maori Diet .. .. .. • • • • • • • ■ • ■ • ■ • • 62-58

REPORTS.

The Director-General of Health to the Hon. the Minister of Health, Wellington. I have the honour to lay before you the annual report of the Department for the year 1939-40.

PART I.— GENERAL SURVEY.

Introduction. In the earlier part of the year arrangements in connection with the introduction of hospital and maternity benefits under the Social Security Act threw an extra load on the Department, while the outbreak of hostilities in September necessitated the diversion of departmental activities in increasing degree to work directly associated with the nation's war effort. The vital statistics for 1939 compare favourably with those of the previous year. There was also a relatively low incidence of the common infectious diseases. Vital Statistics., (Exclusive of Maoris.) Death-rate. The death-rate was 9-20 per thousand mean population, as compared with a rate of 9-71 in the preceding year. There was a marked decline in the number of deaths from pneumonia and measles, which accounted for part of the fall in the death-rate.

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Infant Mortality. The infant-mortality rate was 31-14 per thousand live births, in comparison with 35-63 in 1938. The 1939 rate is the second lowest recorded, and was only beaten by the rate of 30-96 in 1936. Still-births. The still-birth rate was 31-21 (27-3 in 1938). This is the highest rate since 1930. Birth-rate. The total births were 28,833, equivalent to a rate of 18-73 per thousand mean population. The number of births registered is the highest since 1922 and the birth-rate the highest since 1930. Maternal-mortality Rate. The maternal-mortality rate (including deaths from septic abortion) was 3-64- per thousand live births, as compared with 4-07 in 1938. When the deaths from septic abortion are deducted the maternal mortality rate is 2-95. Infectious and otheb Diseases. (Exclusive of Maori unless otherwise stated.) The total number of cases of notifiable diseases in 1939 was 3,260, as compared with 3,790 in 1938. Scarlet Fever. There were 480 notifications of scarlet fever, with 2 deaths. The corresponding figures for the previous year were 662 cases and 2 deaths. The death-rate of 0-01 per ten thousand was the same as in 1.938. Diphtheria. Five hundred and seventeen cases of diphtheria were notified in 1939, as compared with 786 cases in 1938. Twenty-four deaths were recorded, giving a death-rate of 0-16, as compared with 31 deaths and a rate of 0-20 in 1938. The report of Dr. Turbott, Medical Officer of Health, Hamilton, on the control of diphtheria in a rural health district which is published in the Appendix contains encouraging evidence as to the value of active immunization in the prevention of this disease. Immunization campaigns were carried out in other health districts. Dr. F. S. Maclean, Medical Officer of Health, Wellington, reporting on such a campaign conducted by Dr. Wyn Irwin, makes this comment " Viewed purely as an economic proposition the wholesale immunization of young children would seem to be well worth while. The cost of hospital treatment alone of 200 children suffering from diphtheria and requiring on an average six weeks treatment each, would probably amount to at least £4,000. To this must be added the school-time lost to patients and their contacts, and the incalculable cost of the inevitable deaths or resulting invalidity. If the school population of the Wellington Hospital Board area were immunized and it became the practice thereafter to immunize pre-school children between the ages of six months and one year, a maximum total of about 3,000 woidd need immunization yearly. This would be far cheaper than providing hospital treatment for 200 children, and that it would be effective has been clearly shown by the experience of Hamilton and other Canadian cities." Enteric Fever. The number of notifications of enteric fever was 61, with 4 deaths, giving a death-rate of 0-02 per 10,000. In 1938 the death-rate was 0-05. The price for freedom, from this group of diseases is constant vigilance exercised particularly in areas with a large Maori population. Influenza. The death-rate from influenza (all forms) was 1-10 per 10,000, in comparison with 0-88 in 1938. Poliomyelitis. Forty-nine notifications were received, of which 8 were of non-paralytic cases. Through the generosity of Lord Nuffield, iron lungs " have now been supplied to 33 Hospital Boards for treatment of cases of threatened respiratory paralysis and other conditions. Lethargic Encephalitis and Cerebrospinal Meningitis. One case of the former (7 in 1938) and 22 of the latter (24 in 1938) were notified. Whooping-cough and Measles. Deaths from whooping-cough numbered 2 (21 in 1938), while 8 deaths were reported from measles m comparison with 163 in 1938. Puerperal Sepsis. Sepsis following childbirth was responsible for 16 deaths (21 in 1938). The deaths due to sepsis following abortion number 20 (30 in 1938).

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Tuberculosis. There were 613 deaths from tuberculosis (all forms), as compared with 597 in 1938. The death-rate per 10,000 for the past five years is as follows

It will be seen that the rate for respiratory tuberculosis is higher than in 1938, but the rate for non-respiratory tuberculosis is much lower than in 1938, and, indeed, is the lowest rate yet recorded in New Zealand. In this series of reports attention has often been drawn to the Department's anti-tuberculosis work and to the special problems constituted by the high incidence of the disease-in the Maori people. It might be profitable at this stage to refer to some of the measures adopted in this country for combating tuberculosis. (a) Case-finding. —The greatest practical difficulty in connection with tuberculosis is to find cases while still in the early or minimal stages. It is unfortunately still true that cases are often not detected until long after infection has occurred or even in some instances do not come under notice of the Department until after the death of the patient. Early detection of the disease is in the interest of the individual and of the community. On this point Dr. Gilberd, Medical Officer of Health, Whangarei, states : — " Although the number of notified cases is sufficient to make us realize the magnitude of the problem, the true tuberculosis position is not known for the following reasons : — " (1) Failure of many cases to seek medical advice : " (2) Missed diagnosis in many who have sought medical advice (this because of the lack of diagnostic facilities and specialist opinion) : " (3) Failure of medical practitioners to notify cases or suspect cases." While the notification by practitioners of cases which come under their notice remains the principal source of information in regard to the incidence of the disease, growing importance is attached to the examination of contacts and groups specially exposed to infection, such as nurses. Increasing attention is being devoted to this type of work. (b) Institutional Beds— There are five sanatoria in New Zealand for treatment of early and moderately advanced cases of tuberculosis. These provide accommodation for 612 cases. In addition, there are 556 beds in hospitals reserved for the accommodation of advanced cases. Altogether then there are nineteen beds available for each ten deaths which occur annually, a ratio which compares favourably with that of most countries, although still all too few for effective work. . . (c) Tuberculosis Clinics. —Stationary clinics have been established m the four principal cities of New Zealand. These, in the main, do effective work, although in some cases they are staffed far from generously and are handicapped by lack of proper accommodation and equipment. In addition, a system of visiting clinics has been brought into operation whereby tuberculosis specialists visit the various secondary towns at regular intervals. By this means cases that have been discharged from hospitals and sanatoria can be kept under observation, suspect cases can be referred for examination by a competent medical authority, and contacts of actual cases can be kept under close supervision. This system, first developed in the South Island, has now extended over the whole of New Zealand except the Auckland Province. ... (d) Hutments. —In the case of Maoris, hutments are provided as a means of segregating active cases of tuberculosis in their own homes under the supervision of the district nurse. They are intended to supplement, but not to replace, the tuberculosis hospital. Under the ideal system every Hospital Board should have attached to its principal institution an annexe or ward for the accommodation of patients suffering from pulmonary tuberculosis. Such an annexe or should act as a clearing-house through which all patients should pass. Here the nature and extent of the lesion determined and the patient should be educated as to precautionary measures which should be adopted to safeguard all contacts. From the annexe, cases should be distributed to their own homes for domiciliary treatment, or to the sanatoria where this type of institutional care is indicated. Possibly even in some cases the condition might be such as to necessitate the patient remaining under treatment in the annexe itself. At present the Department is giving consideration to making a special grant to certain Hospital Boards in districts where there is a relative preponderance of Maoris so as to facilitate the building of special blocks for the accommodation of Maori patients suffering from tuberculosis. . (e) Medical Examination of School-children.—The percentage of all forms of tuberculosis found in routine examinations of school-children during the year was o'o2 for Europeans and 040 for Maoris. The supervision of children in contact with tuberculous cases was carried out by the School Medical Officers. Co-operation has been maintained with tuberculosis specialists to ensure periodic expert examination. Reference to this work appears in the School Hygiene Report.

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Respiratory Non-respiratory Tuberculosis * oar ' j Tuberculosis. Tuberculosis. (all Forms). 1935 .. .. .. 3-18 0-71 3-89 1936 .. .. .. ■■ •• 3-62 0-94 4-56 1937 .. .. .. 3-28 0-63 3-91 1938' 3-17 0-76 3-93 1939 .. .. .. .. 3-39 0-59 3-98

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(/) Children's Health Camps.—Many thousands of children have passed through these camps. The results have demonstrated the good which can be done to badly-nourished children by a simple regime providing adequate rest, fresh air, sunshine, and proper feeding. (g) Other Measures include those in general use the world over, such as amelioration of undesirable housing conditions, and town planning ; the erection of open-air schools ; the provision of free milk for school-children ; the extension of district nursing ; the control of milk-supply ; tuberculin-testing of herds; health education and the investigation into the incidence of tuberculosis among specially selected groups such as nurses. A rigorous system of medical examination of candidates for admission to training-schools for nurses has been instituted. This examination includes a Mantoux test and an X-ray of the chest. Applicants are engaged whether they have a positive or a negative Mantoux reaction, but the negative reactors are watched carefully and re-examined at stated intervals. Periodic X-ray examinations of chests of all nurses in training is usually undertaken. The campaign against tuberculosis is being waged along these lines. The problem, of course, is social and economic as well as medical. Venereal Disease. Ihe organization for the treatment of venereal disease was strengthened during the year. Steps were taken for the appointment of five specialist Medical Officers designated as Assistant Inspectors of Hospitals. The functions of these officers are :— (a) To visit periodically, but not more often than once a quarter, all general hospitals in their areas ; to report upon the existing facilities for treatment of V.D. ; and to make recommendations for ensuring that the treatment facilities are adequate. (b) To advise Medical Superintendents of Public Hospitals and Medical Officers in charge of V.D. Clinics on all matters relating to treatment. (c) To be available in the areas visited, to see, in consultation with private practitioners, cases upon which private practitioners desire expert advice. (d) To advise the Army Department upon all necessary measures to suppress and limit any outbreaks of V.D. in connection with Military Camps. A widespread incidence of syphilis was discovered amongst the Maoris resident in part of the Whakatane district. As a first step a survey was made of the affected area, and Wasscrmann examinations were carried out of all members of the population over the age of five. Of 896 individuals examined, 121. (13-5 per cent.) were found to give a positive Wassermann reaction. The next step was to give the necessary treatment. This was done by appointing Dr. Maaka as full-time Medical Officer to the area, with the duties of providing a general-practitioner service as well as the necessary anti-syphilitic treatment. There is no reason to believe that the high incidence of syphilis found in this group of Maoris is to be found elsewhere. In order to determine this point, however, instructions were issued for examination of specimens of blood from Maori patients entering hospital for any reason as well as from any Maori women seen ante-natally. The results so far are reassuring. Cancer. Cancer-control has been established on a sound basis by the New Zealand .Branch of the British Empire Cancer Campaign Society. Consultation clinics, available to rich and. poor alike, are doing invaluable woik. During the year 920 new cases attended these clinics, and are under observation Ihe Auckland Division of the Society has been active in developing a plan to carry out statistical research into cancer in New Zealand, and has raised funds for this purpose. The Research Officer of the Society (Dr. A. M. Begg), who is working in London with Dr. Gye, F.R.S., at the Imperial Cancer Research Fund Laboratory, was granted additional leave of absence because of the importance of the work upon which he is engaged. Hydatid Disease. The campaign against this disease was continued along lines outlined in previous reports. The hydatid exhibit prepared for the Department by Dr. E. W. Bennett, of the Hydatid Research and Prevention Department at the Otago Medical School, created widespread interest among visitors at the Centennial Exhibition. Instructions for administration of arecoline hydrobromide tablets to dogs were revised, and 100,000 copies printed for distribution to dog owners. Repobts of Divisional, Directors, Public Hygiene. Dr. Ritchie in his report gives fuller statistics for the year. Problems associated with watersupplies, sewage disposal and treatment, infectious-disease control, industrial and Maori hygiene, and food and drugs inspection have received attention. A large amount of work was done in connection with the Dangerous Drugs Act and Poisons Act. The regular inspections of pharmacists' records that have been carried out have resulted in considerable improvements, and it is now comparatively rare to find a pharmacist whose books are not carefully kept. Military duties associated with the sanitary supervision ol camps and aerodromes, and war-emergency regulations in connection with the control of drugs and other essential medical supplies, have widened responsibilities of officers.

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School Hygiene. Measures for the promotion of the health of children (kindergarten, primary, and secondary) are reviewed in Dr. Elizabeth G-unn's report. More Native school children were medically examined, and extensive diphtheria-immunization campaigns were carried out by School Medical Officers. Hospitals. The maintenance estimates of all Boards provided for a net expenditure of £1,964,604 3s. Id., of which £953,998 10s. 6d. was required to be contributed by levy on local authorities and £1,010,605 12s. Vd. by subsidy from the Consolidated Fund, a total increase of £278,691 13s. compared with the estimates of the previous year. This was accounted for mainly by an increase in hospital-maintenance expenditure. It is gratifying to record a further decrease in requirements for charitable-aid expenditure, the estimate for the year being £33,486 less than that for 1938-39. The maintenance funds of Boards have, however, benefited considerably during the year by the introduction, of hospital benefits and maternity benefits under Part 111 of the Social Security Act, 1938. The rates of payments in respect of these benefits had not been decided when Boards were required to furnish their estimates in April, 1939, and income from these sources was not, therefore, included in estimated receipts. It is apparent from a preliminary examination of estimates from 1940-41 that the total surpluses in the maintenance accounts of all Boards as at 31st March, 1940, due to these payments reached a substantial amount. The surpluses will, however, reduce the amount to be provided by levy and subsidy for maintenance requirements in 1940-41. The continuation of building activities of Boards is reflected in the increase of £38,208 lis. Bd. in requirements from levy and subsidy for capital purposes and provision of expenditure of £1,346,281 12s. 10d. from loan-moneys. It is to be noted, however, that the estimated expenditure from loans included provision made in previous years and not proceeded with when the estimates were prepared. In this connection £605,036 15s. lOd. of the amount provided above is in respect of loan-moneys provided for and actually raised prior to Ist April, 1939. The usual statistical and financial information will be published in a special Appendix to this report when the final accounts of Boards are available. Nursing. A Nursing Council and a Voluntary Aid Council were set up for the organization of registered nurses and the training and organization of voluntary aids in time of national emergency. Miss Lambie, in her report, outlines, among other important matters, steps taken to ensure an adequate nursing service to meet the military and civil needs of New Zealand. Forty additional district nurses and 4 new Nurse Inspectors were appointed. These appointments will considerably strengthen the attack against tuberculosis, particularly in country areas and among the Maori population. The Nurses and Midwives Registration Amendment Act, 1939, provides for the registration and training as " nursing aids " of persons who, not being qualified to be registered as nurses, have sufficient training to undertake nursing duties. The Act also provides that nurses must obtain annual practising certificates and that registration of nurses may be suspended on the ground of misconduct. Maternal W elf are. The report of Dr. Paget shows what has been done in the interests of maternal welfare. It is satisfactory to find some improvement in the situation as shown in the fall in the maternal-mortality rate and in the number of deaths from septic abortion. During the year a beginning was made on research work by the Obstetrical Committee of the Medical Research Council. Dental Hygiene. The dental clinic and training-school in Wellington is now completed. This handsome, well-appointed building will serve as a treatment centre for the children of the Wellington Metropolitan area and at the same time be the training depot to supply the Dominion with dental nurses. The School Dental Service has developed to the extent that treatment centres number 321 and 101,701 children receive regular dental treatment and instruction in oral hygiene. There is now a staff of 21 dental officers, 10 trained nurses, and 232 school dental nurses, together with 156 student dental nurses undergoing training. Maori Hygiene. The Maori population for 1939 was 89,092. The death-rate for the year was 19-92 (24-31 in 1938); the infant-mortality rate was 114-92 per 1,000 live births (153-26 in 1938). The Maori birth-rate was 46-20 per 1,000 population, as against 42-37 for 1938. Excess of births over deaths gives the Maori race the satisfactory natural increase of 2-63 per cent. The death-rate from all forms"of tuberculosis was 4.4-00 per 10,000 of population (pulmonary, 33-67 ; other forms, 10-33). The usual conferences of Medical Officers of Health were held. Discussions centred mainly round the provision of additional hospital beds and hutments for treatment of tuberculosis and the provision of water-supplies for Maori settlements and privies for Maori houses. Steps were taken to apportion on an equitable basis amongst the different health districts moneys provided in the estimates for this purpose.

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Dr. L. S. Davis, Medical Officer of Health, Gisborne, in his report discusses problems of Maori Hygiene, and in doing so comments on the growing measure of co-operation from the Maoris :— " The measles epidemic of last year which created an absolute necessity to avail themselves of nurses' treatment has tended to break down the last threads of reserve of these people, and an entrance to practically all their homes is now assured for the district nurses. The reluctance on the part of many of the Natives to seek treatment, which has been gradually disappearing during the past few years, has now almost completely gone, and I feel that this will herald a period of greater progress in Maori hygiene, for it is the superstitious class of Maori who has in the past provided the nucleus for outbreaks of such diseases as typhoid and dysentery." Opportunity is being taken to point out defects in sanitation and have them corrected if funds are available. Enteric fever is much more prevalent as one might expect amongst the Maoris than the Europeans. On this point Dr. Cook, Medical Officer of Health, Palmerston North, writes :— " The incidence of 4 European cases in a population of 180,000, and 22 Maori cases in a population of 10,600 illustrates one of the penalties of an unhygienic life. The problem in this health district as affecting Maoris is interesting, because the incidence is considerably higher than was my experience in the North Auckland district over a period of six years. The disease is particularly prevalent in the Hawke's Bay and Horowhenua areas, which are alike in that they are flat, alluvial plains where conditions are prone to lead to overcrowding of land, and soil and water pollution. Other than these peculiar physical features in Hawke's Bay and Horowhenua areas, Native housing conditions do not vary to any degree throughout the health district. In North Auckland, where the Maori population is considerable, to some extent the same phenomena occurred; the incidence was highest in the flat alluvial valleys or other flat alluvial ground. " A similar epidemic, in my opinion due to overcrowding of land and soil pollution, was experienced in Tangoio, where over twelve cases occurred in a small crowded settlement, formed as a temporary measure of relief following the disastrous flood of April, 1938. After a few cases of the disease had occurred in one household, investigation revealed that one urinary carrier had been the cause of the whole epidemic, the spread having occurred, no doubt, by infected hands in the home, but outside of this probably from soil contamination, despite the fact that there were ample privies in the settlement. The experience of this health district, as elsewhere, has demonstrated that typhoid fever is due to the failure of the application of well-known hygienic principles, but it would appear that the incidence of the disease is highest in particular areas where overcrowding and soil pollution due to certain physical features enable the failure of hygienic principles to operate more freely." Dr. C. B. Gilberd, Medical Officer of Health, Wbangarei, points out: — "... The histories of contacts with typhoid-fever cases illustrates the complexity of the problem of locating them all, and the large number of contacts who move rapidly over a wide area being potential foci of infection. The absence of epidemics under these circumstances clearly illustrates the protective value of T.A.B. inoculations, especially when the lack of sanitation in many areas, is taken into consideration." In the East Coast Health District a number of cases appear to have originated from an actual carrier. Three cases were traced from eating shell-fish from an infected source, two of these being from the beach near the Gisborne sewerage outfall. Dr. Turbott, Medical Officer of Health, Hamilton, in a report included in the Appendix on the progress in prevention of typhoid in Maoris, shows the value of yearly inoculation campaigns, reinforced by sanitation drives in lowering the incidence of preventable intestinal diseases amongst the Maoris. With an improving standard of sanitation and water-supplies, extended use of public hospitals and of the services of our district nurses, the extension of the School Dental Services and milk-in-schools scheme, we may look forward to improvement in the health of the Maori people. SociAij Security. Medical, Hospital, and Allied Benefits under Part 111 of the Social Security Act. The preliminary work which had been undertaken in relation to benefits under Part 111 of the Social Security Act was outlined in the previous report. In accordance with, the Government's decision at the beginning of the year covered by this report, initial administrative efforts were directed to the introduction of maternity benefits and hospital benefits, which were duly brought into operation. The main details of the arrangements for these two classes of benefits are set out in this report. Maternity Benefits. This class of benefits was made available on 15th May, 1939, in respect of the following types of services :— (i) Treatment in maternity hospitals maintained by Hospital Boards : (ii) Treatment in the State St. Helens Hospitals (at Auckland, Wellington, Christchurch, and Dunedin) : (iii) Treatment in licensed private maternity hospitals : (iv) The services of obstetric nurses in the home : (v) The services of medical practitioners.

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In respect of treatment in a maternity hospital maintained by a Hospital Board, payment is made from the Social Security Fund to the Hospital Board at rates prescribed by regulations of the 21st April, 1939. The rate of payment is £2 ss. for the day or days of labour, and 12s. 6d. per day for the fourteen days following the date of birth of the child. Where medical attendance is afforded at confinement by a Medical Officer in the Board's employ an additional £2 is payable from the Fund to the Board. The amount so paid to the Board must be accepted in full satisfaction of its claims in respect of the services to which the payment relates. Treatment in the State St. Helens Maternity Hospitals is similarly free of charge so far as the patient is concerned. Benefits in respect of treatment in licensed private maternity hospitals are governed by the contracts with the licensees. In every case payment is made from the Fund at the rate of £2 ss. in respect of day or days of labour and at the rate of I2s. 6d. a day for each of the fourteen days succeeding the date' of birth of the child. Of the 189 private maternity hospitals in the Dominion, 186 had at the date of this report entered into contracts to provide benefits. In some cases the licensees' contract requires them to accept such payments in full satisfaction of their claims in respect of the period mentioned, and in other cases they are permitted under their particular contract to make a specified additional charge on the patient. Of the 186 under contract at present there are 32 who have agreed to accept fees from the Fund in full satisfaction, 121 who are permitted to make an additional charge in all cases, and 33 who accept payment from the fund in full satisfaction for certain accommodation and are permitted to make an additional charge for other accommodation. Maternity benefits in respect of the services of obstetric nurses in the home are also subject to contracts with individual maternity nurses and midwives. For nursing attention at confinement, the fees payable from the Fund are set out in the contract as follows :— " (a) For services on the day or days of labour, the fee for a registered midwife, acting in the capacity of a midwife shall be two pounds (£2), and the fee for an obstetric nurse acting in the capacity of a maternity nurse (whether registered as a midwife or as a maternity nurse) shall be one pound (£1). " (b) For services during the confinement period, subsequent to the birth, of the child, the fees shall be — " (i) For a visiting obstetric nurse, five shillings (55.) a day for each of the fourteen days immediately succeeding the date of birth of the child. " (ii) For any obstetric nurse (not being a visiting obstetric nurse), thirteen shillings (135.) a day for each of the fourteen days subsequent to the birth of the child during which, in accordance with the contract, she resides on the same premises as the patient." In addition to fees for nursing services, provision is also made in the contract for the payment from the Fund of actual and reasonable locomotion expenses incurred by the nurse in affording the services. The normal fee for nursing attendance on a full-time domiciliary basis covering the full confinement period ending fourteen days after the date of birth of the child is £11 2s. where an obstetric nurse acts in the capacity of midwife (that is, without a doctor in attendance), and £10 2s. for an obstetric nurse acting in the capacity of a maternity nurse only. The normal fee payable to a part-time visiting nurse is £5 10s. or £4 10s. dependent on the capacity in which she attends the patient. These payments from the Fund must be accepted by the obstetric nurse in full satisfaction of her claim for nursing services in relation to maternity benefits. The number of obstetric nurses who at this date had entered into contracts to provide maternity benefits is 290. The general arrangements for medical services in relation to maternity benefits contemplated by the Social Security Act, 1938, involved the completion of contracts with individual medical practitioners. Offers of contract were circulated to practitioners on the 22nd April, 1939. In the ensuing three months only some thirty practitioners had notified acceptance. As the result of further negotiations with representatives of the New Zealand Branch of the British Medical Association, new arrangements affecting these medical services were proposed by them. These proposals wore ultimately given statutory effect, the relevant legislation being contained in sections 11 to 15 of the Social Security Amendment Act, 1939. The main details of the arrangements which came into operation on the Ist October, 1939, are as follows :— (i) In respect of medical services in relation to maternity benefits a scale of fees has been fixed by agreement between the Minister and the Council of the New Zealand Branch of the British Medical Association : (ii) Except in the circumstances explained in the three succeeding paragraphs, every doctor affording services covered by the scale of fees must accept the fees from the Fund in full satisfaction of his claim for the services : (iii) Any practitioner who formally notifies the Minister of his unwillingness to provide services in relation to benefits is ipso facto excluded from the arrangements. No payments may be made from the Fund to any such practitioner, and his fees are a liability of his patients. (Only six practitioners had at the date of this report notified their unwillingness to provide services in relation tb benefits.) The names of such practitioners are listed for public information at post-offices and departmental offices : (iv) Any practitioner officially recognized as an obstetric specialist is entitled to charge the patient an additional fee over and above that payable from the Fund. (At the date of this report twenty-two practitioners had been officially recognized as obstetric specialists.) Their names are listed at local post-offices, &c., for public information ;

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(v) The only other circumstances in which fees are payable by the patient in respect of services in relation to maternity are where the patient for private reasons does not wish to avail herself of benefits and notifies the doctor to that effect. (vi) Medical services covered by the scale of fees includes attendance in relation to a miscarriage, provided the patient had received approved ante-natal advice prior to the occurrence : (vii) The scale of fees also includes services rendered in the capacity of a consultant or an anaesthetist acting with a practitioner affording services in relation to maternity benefits : The precise scope of the services are set out in a departmental booklet issued for public information. Not all medical services in relation to maternity are included — e.g., the operation known as Csesarean section is expressly excluded : (vii) In addition to fees for services, the scale of fees provides for payment of mileage fees in respect of visits in certain circumstances. Supplementary Maternity Benefits. By regulations of the 19th July, 1939, maternity benefits are made available in cases where a woman has for special medical reasons to be confined in a licensed medical and surgical hospital. Supplementary maternity benefits have also been made available by regulations of 16th May, 1940, in cases where a woman who has made arrangements for admission to a contracting private hospital or for attendance in the home by a contracting obstetric nurse, but owing to emergency is prevented from availing herself of the services arranged for, and receives alternative services of an approved character.. Maternity Benefits •paid. Up to the 31st March, 1940, maternity-benefits payments were made in respect of 7,642 patients of Hospital Board hospitals, 1,825 patients of St. Helens Hospitals, 13,185 patients in licensed maternity hospitals, and 1,854- patients attended in private homes by obstetric nurses, a total of 24,506 relating to a period of approximately ten months. Up to the same date payments had been made to medical practitioners in respect of 10,308 patients. The greater proportion of these payments are in respect of attendance afforded since Ist October, when the present arrangements for medical services commenced. Hospital Benefits. Free maintenance and treatment in State mental hospitals has been provided since Ist April, 1939. Hospital benefits, which consist of payments from the Social Security Fund in respect of hospital treatment, were commenced on the Ist July, 1939. This class of benefits applies to hospital treatment afforded in any hospital maintained by a Hospital Board, including, in addition to general hospitals, the tuberculosis hospitals and sanatoria and infectious-disease hospitals, as well as approved hospital wards of homes for aged people. For the present, hospital benefits are payable in respect of treatment afforded to in-patients only. Payments from the Fund to Hospital Boards are made at the rate of 6s. a day for each patient, and such payments must be accepted by the Board in full satisfaction of its claim against the patient. In other words, all hospital treatment received on and after Ist July, 1939, by in-patients of Hospital Board institutions is free of charge to patients. Claims totalling £514,000 were received from Hospital Boards up to the 31st March, 1940. These claims covered the period Ist July, 1939, to 29th February, 1940, and the amount therefore represented an average of slightly more than 7,000 patients daily during that period in receipt of free treatment. For hospital treatment afforded to a patient in a licensed private hospital payment from the Fund at the same rate as for public hospital treatment is made directly to the licensee, who is required to apply the payment from the Fund in reduction of the total charge for hospital treatment. The patient is entitled to the whole benefit of any payment made from the Fund on his or her behalf, and payment may, in fact, be withheld unless the Minister is satisfied that the amount payable from the Fund will, up to the full extent of such amount, be applied in reduction of the charges that would be payable by the patient. For the period Ist July, 1939, to 29th February, 1940, a daily average of approximately 1,150 patients of private hospitals received hospital benefits. Hospital benefits are also available in respect of maintenance and treatment afforded' to any in-patient of Queen Mary Neurological Hospital, Hanmer Springs, or of the Botorua Sanatorium. The fees chargeable to patients of the two institutions have been reduced by 6s. a day, and corresponding payment is made from the Social Security Fund to the credit of the Departments controlling these institutions. Genekal. Milk-in-schools Scheme. Milk was made available to 223,694 pupils, representing 79-3 per cent, of the school population, in comparison with 67 per cent, for the previous year. Bottled pasteurized milk was available to 214,665 of these attending 1,202 schools ; malted-milk powder to 5,351 attending 1 17 schools ; and milk for cocoa-making purposes to 3,678 attending 23 schools.

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The value and popularity of this service continues to be stressed by mcdical officers and head teachers. The following from many favourable statements received from head teachers might well be quoted : — Country Schools: — " The milk is appreciated by all children, and a better standard of health is evident." " I consider the malted milk in schools a great success. Between 80 per cent, and 90 per cent, of the pupils eagerly anticipate the daily distribution of malted milk at lunchtime, and the improvement in response, especially of the Maori scholars, is, I think, largely due to the extra nourishment." " Even to a layman it is obvious that the children are deriving benefit. It is particularly beneficial to those children who have lunch at school, and to those who travel a long way." " Although the children are country children, many of them do not take milk at home, yet they seem to relish the school milk —a splendid scheme." City Schools: — " The scheme is working satisfactorily, and an improvement in health and capacity for work is noticeable in the pupils accepting rations." " Believe that this daily supply of food to our congested area is of inestimable value to very many pupils. Believe, too, that this daily bottle of milk is an incentive to full attendance —at least we have noted a falling in attendance when the supply was cut ofE." Convent Schools: — " The children love it, and the Sisters are very pleased with results." Maori Girls: — " It has greatly assisted in the health of the girls." Nutrition. The New Zealand Medical Research Council set up a special Committee under Dr. Malcolm, Professor of Physiology, Otago University, which is studying the subject of nutrition, with special reference to New Zealand foodstuffs and New Zealand conditions. A technical officer has been attached to the Committee on a full-time basis, and in addition a Medical Officer has just been appointed to the staff of the Department, who will carry out research in connection with infant nutrition. Dr. Turbott carried out some research work into the diet of Maoris, and an account of this appears in the Appendix. A booklet entitled " Good Nutrition " was prepared under the auspices of the Otago Medical School, the Medical Research Council, and the Department. This booklet will form the basis of the Department's teaching on the subject of diet and should be of distinct value towards the better education of the people in the matter of a healthy diet. Health Camps. This year considerable progress has been made with the establishment of both permanent and secondary health camps. At the 31st March, 1939, the King George V Memorial Fund amounted to a sum of £181,936 4s. 6d., and from this sum payments amounting to £16,020 14s. Id. have been made. Further expenditure amounting to £75,683 4s. has been authorized for the erection of buildings or the purchase of land, while additional proposals, amounting to £19,600 are awaiting the consideration of the trustees. The finance of the camps for maintenance purposes benefited to the extent of some £2,000 by the sale of health stamps and a grant of £10,393 from the Christmas art-union proceeds. The Wellington camp at Otaki and the Wanganui camp are in full working-order. A suitable property has been purchased at Christchurch, and plans have been prepared for the Dunedin camp at Roxburgh. Approval has been granted for the establishment of secondary camps at Gisborne and Nelson. Health Education. A feature of the Department's health educational work was the display in the Government Court at the Centennial Exhibition. The main exhibit was entitled " The Highway to Health and Happiness." The subject demonstrated was the healthy family, and was worked out along two lines —(1) Good Health : How to develop it; and (2) Good Health : How to protect it. The theme was advanced progressively in successive bays arranged in the form of an irregular ellipse. The significance of the various parts of the display was explained through the use of a robot in the form of a walking and talking doctor. There were also smaller exhibits dealing with nutrition, goitre, and hydatid disease, prepared for the Department under the direction of officers of the Otago Medical School. A wide range of pamphlets and other health literature was distributed. A selection of health posters was obtained from London, and some of these, as well as others presented to the Department by the Waikato Winter Show Association, were shown and attracted considerable attention. The following films were produced and shown at the Exhibition : " School Dental Service " ; " Coming Generation or School Medical Service Work " ; " Day at a Health Camp " ; " Health Activities in Secondary Schools " ; " St. Helen's Hospital "; " Kia- Ora," for use among the Maori people ; " Hydatid," produced by Hydatid Research and Prevention Department, Medical School, Otago University. In addition, the following films were obtained for the film library : " The Fly " ; " Body Defence against Disease " ; " Nutrition Cartoon," and " The Filter."

2—H. 31.

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During the year a number of reference works were added to the library, which was also enriched by a collection of departmental reports and other publications obtained from overseas health authorities during the course of my study tour abroad. The library is now affiliated with the New Zealand Library Association. Boards associated with the Department. The Board of Health, Medical Council, Medical Research Council, Dental Council, Nurses and Midwives Registration Board, Opticians Board, Masseurs Registration Board, and the Plumbers Board continued their work during the year. Reference to the work of the Nurses and Midwives Registration Board appears in the report of the Director of the Division of Nursing. Medical Research Council. It is regretted that owing to paper shortage it is not possible at present to print the reports of the Medical Research Council. However, copies of the following are available'for those interested: Nutrition Committee; Obstetrical Committee; Thyroid Committee; Hydatid Committee; and Tuberculosis Committee. The Dental Committee's report is published in the New Zealand Dental Journal, September, 1939. The work of the Council has gone steadily forward, and a sum of £3,643 was expended during the year out of an amount of £7,655 available. The report of the Nutrition Committee contains a comprehensive diet survey carried out among basic-wage earners of New Zealand by Miss E. C. G Wilson, M.H.Sc. The results of an inquiry into the consumption of milk in rural households carried out by the Women's Institutes assisted by the Committee appears also in the report. The Thyroid Committee records the gazetting of amendments to the Sale of Pood and Drugs Regulations as relating to iodized salt. The level of iodine has now been raised to the amount recommended by the Medical Research Council. These regulations came into force on the Ist November, 1939. They provide that iodized salt shall be salt prepared for table or culinary use by the addition of potassium iodide (KI) or sodium iodide (Nal). It shall contain not less than 0-75 of a part and not more than 1-5 parts of iodine (calculated as potassium iodide) to every twenty thousand parts of salt. The Hydatid Committtee, as represented in the Department of Hydatid Research and Prevention, Medical School, Otago Univerity, was active in educational work and in chemical, laboratory, a,nd statistical research work. The Tuberculosis Committee's work developed along the following lines: Detection of tuberculosis among the Maoris; survey of tuberculosis among nurses; and finalizing of arrangements for the typing of tubercle bacilli. The Medical Officer for Obststrical Research, P. 0. Bennett, M.D., presented a report entitled " A Statistical Inquiry into the Incidence, &c., of the Toxaemia of Pregnancy in New Zealand." Reference to this and the work of the Obstetrical Committee appears in the report of the Director of Maternal Welfare. The Dental Committee was active in correlating all dental research work within the Dominion. The Medical Research Council is grateful for the assistance and advice given by the members of these committees. Overseas Study Tour. An account of my overseas study tour rendered possible through the generosity of the Rockefeller Foundation is published as a separate report. Recommendations for improvements in our own organization are included in this review of public-health administration in North America, the United Kingdom, and Scandinavia. Staff. In conclusion, I wish to express my thanks for the support rendered me by officers during the year. M. H. Watt, Director-General of Health.

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PART 11. —PUBLIC HYGIENE.

I have the honour to submit my annual report for the year ended 31st March, 1940. SECTION I.—VITAL STATISTICS. (Exclusive of Maoris unless otherwise stated.) POPULATION. The mean population of the Dominion for 1939 was estimated to be 1,539,420, an increase of 19,814 over the corresponding figure for 1938. BIRTHS. The births of 28,833 living children were registered during 1939, an increase of 1,584 over the previous year. The birth-rate per 1,000 of mean population was 18-73. The birth-rate reached its lowest level in 1935, when the rate was 16-17 ; it has increased each year since then, the rates being 16-64, 17-29, 17-93, and 18-73. The last-mentioned rate is the highest since 1930. Whilst some satisfaction can be expressed at the rising tendency in the birth-rate, the increasing percentage of first births to total births indicates that it is largely the result of the increase in the marriage rate during recent years. New Zealand's future cannot be viewed without misgiving unless the position continues to improve. DEATHS. Deaths registered during 1939 numbered 14,158, a decrease of 596 from the number of deaths in the previous year. The crude death-rate was 9-20 per thousand, compared with 9-71 in 1938. During 1938 pneumonia accounted for 613 deaths, in 1939 for only 311. Measles was epidemic in 1938 and 163 deaths were due to this cause, as compared with eight in 1939. Deaths from violence dropped from 999 in 1938 to 881 in 1939. Thus these three causes were responsible for 575 fewer deaths in 1939 than in 1938. Still-births. A still-born child is defined as one " which has issued from its mother after the expiration of the twenty-eighth week of pregnancy, and which was not alive at the time of issue." In 1939 still-births numbering 900 were registered, an increase of 157 over the figure for the previous year. The still-birth rate per 1,000 total births was 30-27, the highest rate since 1930. The rate per 1,000 live births was 31-21. The Principal Causes op Death. The following table gives the main causes of death during the year, the actual number of deaths therefrom, and the death-rates per 10,000 of mean population for each of the last five years:—-

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1939. 1938. 1937. 1930. 1935. Cause. Number. Rate. Rate. Rate. Rate. Rate. Heart-disease (all forms) .. .. 4,279 27-80 27-45 26-25 24-43 23-34 Cancer .. .. .. .. 1,815 11-79 11-76 11-82 11-81 11-18 Violence .. .. .. .. 881 5-72 6-57 5-99 5-79 5-25 Pneumonia .. .. .. .. 311 2-02 4-03 3-36 2-68 1-62 Pneumonia (secondary to influenza), 89 0-58 1-23 0-47 0-68 0-22 whooping-cough, and measles Bronchitis .. .. .. .. 210 1-36 1-32 1-14 1-35 1-34 Broncho-pneumonia .. .. .. 308 2-00 2-33 1-72 1-61 1-63 Tuberculosis (all forms) .. .. .. 613 3-98 3-93 3-91 4-56 3-89 Kidney or Bright's disease .. .. 534 3-47 3-82 3-89 3-96 3-56 Apoplexy or cerebral haemorrhage .. 888 5-77 5-61 5-37 5-09 4-87 Diseases of the arteries .. .. .. 532 3-46 3-62 3-62 2-99 2-96 Senility .. .. .. .. 333 2-16 2-64 2-37 2-55 2-39 Diabetes .. .. .. .. 344 2-23 1-88 1-83 1-59 1-53 Hernia and intestinal obstruction .. .. 108 0-70 0-72 0-81 0-66 0-67 Diseases and accidents of childbirth (puerperal 105 0-68 0-72 0-63 0-62 0-68 mortality) Appendicitis .. .. .. .. 106 0-69 0-77 0-77 0-80 0-72 Diarrhoea and enteritis .. .. .. 70 0-45 0-64 0-33 0-40 0-55 Epilepsy .. .. .. .. 40 0-26 0-32 0-37 0-33 0-29 Common Infectious Diseases. Influenza (all forms, including pneumonic) .. 170 1-10 0-88 0-73 0-94 0-74 Diphtheria .. .. .. .. 24 0-16 0-20 0-16 0-13 0-22 Whooping-cough .. .. .. 2 0-01 0-14 0-08 0-32 0-28 Scarlet fever .. .. .. .. 2 0-01 0-01 0-04 0-05 0-05 Typhoid and paratyphoid .. .. 4 0-02 0-05 0-06 0-05 0-07 Measles .. .. .. .. 8 0-05 1-07 0-02 0-02 0-01

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Heart-diseases (all forms). —The number of deaths from the various diseases listed under this heading continues to increase, but the increase in the crude death-rate is considerably less than in recent years. Increase in the number of deaths and in the death-rate is to be expected with an ageing population. Cancer— Cancer stands second to diseases of the heart as a cause of death, and in 1939, 1,815 deaths were assigned to this cause, an increase of 28 over the previous year. The crude rate rose slightly, from 11-76 in 1938 to 11-79 in 1939. As shown in last annual report, the cancer death-rate, when adjusted to eliminate the effects of the changing age and sex constitution of the populationj has shown no evidence of an increasing tendency for several years.

Tuberculosis (all Forms).

Of the 613 deaths from tuberculosis in 1939, 522 (3-39 per 10,000 of mean population) were assigned to tuberculosis of the respiratory system, and 91 (0-59 per 10,000) to other forms of the disease. Tuberculosis of the Respiratory System.—After two years with a decreasing number of deaths and a declining death-rate the number of deaths in 1939 (522) showed an increase of 40 over those for 1938 (482) and the rate per 10,000 of mean population increased from 3-17 in 1938 to 3-39 in 1939. During the past eight years the latter rate has only once been exceeded, in 1936, when it was 3-62. Of recent years the rate of decline has shown a tendency to decrease, and it is probable that if the position is to be maintained or improved a more intensive campaign against this disease will be necessary. 1 überculosis other than that oj the Respiratory System.—The 91 deaths last year so assigned were distributed as follows (the figures for 1938 being given in parentheses) :— Tuberculosis of the meninges and central nervous system . . .. 34 (35) Tuberculosis of intestines and peritoneum .. .. 12 (19) Tuberculosis of vertebral column .. .. .. .. 7 (18) Tuberculosis of bones and joints .. .. .. ..2(5) Tuberculosis of lymphatic system .. .. .. .. 1(3) Tuberculosis of genito-urinary system .. .. .. .. 7 (] ]) Tuberculosis of other organs .. .. .. .. ..3(3) Disseminated tuberculosis .. .. .. .. .. 25 (21) 91 (115) The number of deaths (91) and the crude death-rate per 10,000 of mean population (0*59) are the lowest recorded in New Zealand. In 1924 the rate was 1-26 per 10,000 (the lowest recorded to that date) a figure more than double the rate experienced in 1939. Of the various forms listed above, only in the case of disseminated tuberculosis was there an increase over the previous year in the number of deaths from 21 to 25. The average yearly number of deaths from this cause during the past ten years was 24-6. Infant Mortality. Deaths of infants numbered 898, and the infant-mortality rate was 31-14 per I 000 live births compared with 35-63 in 1938.

Infant Mortality in New Zealand, 1932-39 (per 1,000 Live Births).

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Number of Number of Death-rate from Year. Deaths from ! D er l0 000 of Year - Deaths from Tubercutosis u erou OS s. j Mean p opulation . Tuberculosis. Me P p 0 p ulat ° 0n . 1934= •• 621 4-21 1937.. .. 589 3-91 1935 .. .. 576 3-89 1938.. .. 597 3-93 1936 .. .. 680 4-56 1939.. .. 613 3-98 i

j " w | I'SSSJS^KsS. 1932 .. 21-30 9-92 31-22 1936 .. 22-31 8-65 30-96 1933 .. 22-81 8-79 31-64 1937 .. : 22-22 8-99 31-21 1934 .. 22-86 9-25 32-11 1938 .. 24-J5 11-48 35-63 1935 .. 22-03 I 10-23 32-26 1939 .. I 21-85 9-29 31-14

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Analysis of Deaths of Infants under one Month of Age, 1939. The following table gives the causes of these deaths during the year : —

The following table shows for the past five years the death-rate per 1,000 total births for still-births and for live births at various ages up to one month.

Rates per 1,000 Total Births.

SECTION 2.—NOTIFIABLE DISEASES. Attached are tables showing the notifications of infectious and other notifiable diseases during 1939. Tables A, B, and C deal with Europeans only. The year was a quiet one, with less than the usual prevalence of infectious disease, the total number of notifications of these and other notifiable diseases being 530 less than during the previous year. From Table D it will be seen that notifications of infectious diseases amongst the Maoris increased from 423 in 1938 to 452 in 1939. Tuberculosis of the respiratory system showed an increase of 64 cases. The problem of tuberculosis in the Maori population is one giving considerable concern to the Department, which is increasing the provision of facilities for treatment.

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frSif TT1 °3 s T3 £ T3 4) DT) d Cause of Death. ' & §5= Total. One Day. § „ g <* I 5 §o <§SJ5 £SJ |§<§ Diphtheria Whooping-cough Influenza .. .. .. .. .. .. 1 .. .. 1 Syphilis Convulsions .. .. .. .. .. .. 1 .. .. 1 Broncho-pneumonia .. .. .... 1 3 2 3 9 Pneumonia .. .. .. .... 1 2 1 1 5 Diarrhoea and enteritis .. .. .. .. 2 2 .. .. 4 Congenital malformations .. 27 53 16 7 3 106 Congenital debility .. .. .. 4 4 3 1 .. 12 Injury at birth .. .. .. 30 37 6 4 1 78 Premature birth .. .. .. 184 91 10 6 .. 291 Other diseases of early infancy .. 27 52 14 5 2 100 Accidental mechanical suffocation Other causes .. .. .. .. .. 8 6 4 5 23 Totals, 1939 .. .. 272 249 64 30 15 630 Totals, 1938 .. .. ..222 307 71 34 24 658

TTnrinr One Day Two Days One Week w W ? Year. Still Births. n n and under and under and under Weeks One Day. Tw0 DayB Qne Week . Two Weeks . and under 1935 .. .. .. .. 29-87 7-93 2-91 6-52 2-19 1-82 1936 .. .. .. .. 28-63 8-88 3-01 5-55 2-54 1-68 1937 .. .. .. .. 28-42 9-11 2-32 6-61 2-20 1-35 1938 .. .. .. .. 26-54 7-93 3-04 7-93 2-54 2-07 1939 .. .. .. .. 30-27 9-15 2-32 6-05 2-15 1-52

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Table A.—Notifiable Diseases in New Zealand for Year ended 31st December, 1939, showing Distribution by Months.

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0 1 Poliomyelitis. jpuerperal Fever. Sal? g ® £ • — oal . i 1- . alSS&fel^cS 1 « » ® «S fe Month. £ | „• | ■! | o- g I g* j g>|§ I 4 I Is sj 1 S a =1 •= if S s 2 s 2 go I Ji § it, § !■ fi |!"E a s ? ! J s s | * li f 1 i! I -§J • » « s ■§, p. sg 5 ea £ Is a & §s g « 2 « § li? 5s • o In ■§ 5 8* -s §£ 5 45 5 § •= K 3 S" a a " °S ogs o % >• 2 a tS" o «" 5 o S S ,q M s 5 S !» fi H HO PM ftfis HHWE-IOI-5 psiffl&«jOfC|P4 EH H EH January .. .. 29 64 9 .. 88 5 2 1 1 51 15 15 5 3 7 .. 5 .. 5 .. 4» 309 266 302 February .. .. 26 34 5 3 93 1 2 ..31 12 3 3 1 3 1 5 2 225 237 282 March .. .. 30 48 4 2 92 1 1 1 3 61 18 19 2 3 1 2 4 2 1 4 1 1 .... 301 336 361 April .. .. 36 43 3 45 1 11 12 41 8 7 1 2 1 1 2 11 2 3 .... 230 369 500 May .. .. 61 71 5 1 79 2 7 18 43 3 8 7 5 1 2 4 2 1 .. 320 403 444 June .. .. 51 76 2 92 1 8 1 2 49 7 6 13 1 4 1 3 1 3 .... 321 354 409 July .. .. 54 64 1 2 74 3 3 1 6 51 8 4 4 3 2 4 1 285 365 335 August .. .. 50 28 5 92 4 1 9 60 6 9 7 1 5 1 2 1 1 2 .... 284 342 366 September .. 34 22 2 2 86 1 1 50 16 8 6 4 1 2 5 1 1 242 253 318 October .. .. 38 21 2 85 1 1 2 42 23 16 10 2 2 2 4 7 1 1 1 .... 261 279 333 November .. 29 29 9 1 90 2 2 1 3 43 11 11 6 1 2 1 .. 33 2 1 277 295 307 December .. .. 42 17 3 73 1 2 2 1 30 4 14 3 2 1 1 6 2 1 205 291 246 Totals, 1939 .. 480 517 46 15 989 22 41 8 57 552 131 J 120 67 12 39 6 20 1 53 39 26 4 13 1 1 3,260 Totals, 1938 .. 662 786 57 7 1,031 24 20 2 36 522 125 j 138 74 10 46 6 21 7 23 161 21 3 8 3,790 Totals, 1937 .. 924 599 45 10 915 13 557 208 42 329 113 185 | 75 12 44 9 32 3 37 19 26 2 4 4,203

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Table B.—Notifications of Cases of Notifiable Diseases by Health Districts for Year ended 31st December, 1939.

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i 1— ; i I : 1 1 i i I I Name of Disease. ! aS. AucHand. Wan", East Cape. wS&n. Canterbury. West Coast. Otago. | Southed. Tota.s. Scarlet fever 4 63 25 ! 6 j 44 4 60 62 j 35 80 15 48 34 480 Diphtheria 42 43 36 13 43 24 77 186 34 o 3 10 1 517 Enteric fever — I „ <a (а) Typhoid 2 10 6 4 2 11 4 3 .. 2 .. 2 .. 46 TuterftSosf ph ° 1 .. :: " "21 '206 "42 "n 28 15 '113 212 24 m 19 105 59 9^9 Cerebrospinal meningitis .. .. .. •• 1 2 .. 2 2 4 5 , "SXSK 1,,... j » • •• i % (б) Non-paralytic 1 - ■ • ■■ 6 "i 57 tsss- :: :: :: :: " * ■« 4 "» i "» - ™ » « * « 21 652 ''".J'S 1 !.!™ childbirth . - 1 20 7 3 11 18 12 6 37 7 ; 7 131 (6) Following abortion or miscarriage .. 1 o9 3 2 2 3 lb 1 ■■ Eclampsia 4 13 5 2 1 10 3 10 o 10 4 67 Tetanus .. .. •• •• •• 1 1 1 •• •" .. , "o " oq Hydatids 6 5 1 9 4 .. 11 1 2 .. 39 Trachoma .. .. .. .... .. z .. .. -• • • A * •• . Ophthalmia neonatorum .. .. .... 8 3 .. .. •• « •• * •• * * Lethargic encephalitis .. .. • • • • • • • • • • • • • • • • • • * • " 9 " * '' -o Food poisoning .. .. .. .. •• 35 1 .. 1 6 •• 8 .. - •• •• •• Baeillary dysentery .. .. .. •. 12 1 .. 3 16 7 .. .. .. • • • • • • Undulant fever .. 2 3 4 1 4 4 4 1 .. 3 26 Actinomycosis .. .. .. 2 1 .. •• •• •• •• •• •• Chrome lead poisonmg .. .. .. •• 1 •• •• •• •• •• iA Beri-beri .. .. .. . • • • 1 • • • • • • Phosphorus poisoning .. .. .. • • • • • • • • • • 1 * * • * * * * * . [J [J - Totals 82 605 204 61 173 124 408 659 115 368 57 269 135 3,260 I

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Table C.—Notifiable Diseases in New Zealand for Year ended 31st December, 1939, showing Distribution by Age and Sex.

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•ii 1 I I ! ! I ' Under 1 to 5 5 to 10 10 to 15 15 to 20 20 fco 25 25 to 30 30 to 35 ; 35 to 40 40 to 45 45 to 50 50 to 55 55 to 60 00 to 65 65 to 70 70 to 75 75 to 80 80 Years Total Cases Disease. t year. Years. Years. Years. Years. Years. Years. Years. Years. Years. Years. Years. Years. Years. Years. Years. Years, and over, at all Ages. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. M. F. Scarlet fever .. .. 3 3 43 46 54 126 27 52 9 16 I 8 27 10 14 3 7 2 6 4 6 1 .. 3 4 2 2 .. 1 1 170 310 Diphtheria .. .. 3 3 58 49 117 108 42 46 6 15 11 20 7 8 3 7 2 3 3 3 1 1 1 254 263 Enteric fever — (а) Typhoid .. 2 2 6 1 2 1 4 5*4 1 3 1 2 3 2 1 1 3.. 1.. .. 1 30 16 (б) Paratyphoid 2 1 .. 2 .. .. 1 2 1 .. 2 1 1 .. 1 .. 1 7 8 Tuberculosis .. .. .... 5 8 8 6 12 18 38 43 66 94 90 97 59 66 29 44 44 21 37 20 41 13 40 13 30 11 12 5 10 2 1 5 1 .. 523 466 Cerebro-spinal meningitis.. 4 3 3 1 1 1.. 1 1 1.. .. 1.. 1 1 1.. 1.. .. 1 13 9 Poliomvelitis — (a) Paralytic .. 6 3 8 3 5 3 2 12 1 . 2 2 2 1 28 13 (b) Non-paralytic 1 1 2 .. 1 1 1 1 6 2 Influenza .. ....1.... 1 112214.. 44123....26234134 1..121 32 25 Erysipelas .. .. 2 1 4 8 9 5 9 2 8 11 11 9 9 27 15 29 21 28 19 35 33 26 21 46 18 29 19 33 18 9 10 13 3 2 3 7 232 320 Puerperal fever — (a) Following childbirth 12 .. 37 .. 45 .. 24 .. 7 .. 6 .. 131 (b) Following abortion or 1 •. 8 .. 27 .. 25 .. 41 .. 16 .. 1 .. 1 .. 120 miscarriage Eclampsia .. . j 8 .. 15 .. 22 .. 11 .. 7 .. 3 .. 1 .. 67 Tetanus .. 1 II 2 1 2 •• •• 3 1.. .. 1 9 3 Hydatids .. 2 1 21 1.. 14 13 32 21.. 1 1.. 12 41.... 4 1.... 22 17 Trachoma .. •• •• 1 • • 1 •• •• •• 1 1 •• •• 1 •• 3 3 Ophthalmia neonatorum .. 6 14 .. .. I j 6 14 Lethargic encephalitis i 1 • • 1 Food poisoning .. 1 1 . • 1 1 27 2 4.. 4 1 3 2 2 1 1 1.. .. 1 44 9 Bacillary dysentery 4 3 | 7 1 2 1 .. 21 2..1 .. 2 .... 4 1 1.. 1 1 2 1.. .. 1.. 1 23 16 Actinomycosis .. 1 j 1 1 1 2 2 Chronic lead poisoning 1 • . 1 • • " • • - • • - 13 Beri-beri .. 1 1 Phosphorus poisoning 1 • • • • • • ...... .. .. 1 Undulant fever .. 1 1 3.. 2.. 2 1 3.. 1 1 1.. 2.. 4 1 .. 2 .. 1 19 7 i i Totals .. .. 18 25 |129 124 219 256 107 132 75 124 146 241 139 250 103 196 66 116 77 80 85 51 82 72 70 53 54 50 35 17 21 17 5 10 6 9 1,437 1,823

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Table D.—Maoris: Notifications of Cases of Notifiable Diseases for Year ended 31st December, 1939.

3—H. 31.

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Name ol Disease. Auckland. Auckland. Auckland. Tauranga. Taranaki. East Cape. Wellington. Marlborough. Canterbury. West Coast. Otago. Southland, j Totals. Scarlet fever ...... .... .. .. .. 1.. 2 3 Diphtheria .. .. .. 4 .. .. .. 7 X 8 1 91 Enteric fever — (a) Typhoid ...... 8 4 3 5 1 17 22 .... .. .. fin (b) Paratyphoid ...... . . .. .. 3 .. 3 Tuberculosis .. .. .. 92 13 33 .. 20 36 69 8 4 4 !! !! "4 283 Cerebro-spinal meningitis...... . . .. 3 Poliomyelitis — (a) Paralytic .. .. .... .. ., .. 1 j (b) Non-paralytic .. .. Influenza Erysipelas .. .. .. 1 1 1 1 1 "4 "4 " 1 " j' '' j' °' " 14 Puerperal fever — (a) Following childbirth .. 2.. 6.. 1 2 4.. j5 (b) Following abortion or miscarriage 1 .. .. . . , . .. .. j Eclampsia Tetanus .. .. .. .. .. .. _ X _ _ '' '' j Hydatids .. .. .... .. .. .. 2 3 5 Trachoma .. .. .. 7 .. 4 .. .. 4 1 1 |' " " " jOphthalmia neonatorum .. .. 3 .. j 1 .. 1 .. 1 '' g Lethargic encephalitis Food poisoning .. .. .. .. .. 3 _. _ _ _ '' '' "' '' "" Bacillary dysentery .. .. .. 1 1 .. U 1 '' " " '' " XJndulant fever .. .. .. .. .. .. _ j Actinomycosis Chronic lead poisoning Phosphorus poisoning .. .. .. .. .. 1 '' ' j Totals ...... 118 19 52 6 35 79 115 13 5 6 ~ 4 452

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Table E. —Venereal-disease Clinics: Cases treated during the Year ended 31st December, 1939.

SECTION 4.—WORKING OF THE SALE OF FOOD AND DRUGS ACT. Table 1. Showing Samples respectively of Milk and other Foodstuffs taken and dealt with during the Year ended 31st December, 1939.

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Auckland. Wellington. | Christchurch. Dunedln. Totals. P. M. F. M. F. M. F. M. F. Number of persons dealt with for first time and found to be suffering from— Syphilis .. .. .. 59 43 18 25 19 11 12 5 108 84 Soft sore .. .. .. .. .. 4.. 7 .. .. . 11 Gonorrhoea .. .. .. 399 141 333 53 328 88 91 90 1,151 372 No venereal disease .. .. 141 38 115 94 38 14 13 4 307 150 Total attendance of persons suffering from— Syphilis .. .. .. 1,353 1,941 1,937 1,022 1,418 419 474 254 5,182 3,636 Soft sore .. .. .. .. .. 34 .. 48 .. .. 82 Gonorrhoea .. .. .. 10,432 1,042 12,487 3,358 12,585 3,248 3,n8 3,073 38,622 Number of persons suffering from— Syphilis .. .. .. 697 766 674 682 302 138 128 80 1,801 1,666 Gonorrhoea .. .. .. 976 656 1,210 373 1,607 684 498 603 4,291 2,316

Samples not complying. Number of , T v Samples N ° m^ er of Health District. taken ' Wirings* Prosecutions issued. recommended. Milk. Other. Milk. Other. Milk. Other. Milk. Other. Milk. Other. North Auckland .. 141 48 78 37 25 2 16 1 Central Auckland .. 3,651 346 3,532 346 183 28 163 26 il 4 South Auckland .. 1,572 152 1,304 126 43 3 43 3 Thames-Tauranga .. 213 12 200 12 36 9 28 9 2 Taranaki .. .. 262 30 118 28 15 5 4 5 9 East Cape .. .. 280 17 244 16 11 .. 10 Wellington - Hawke's Bay 656 184 414 176 38 17 20 12 8 5 Central Wellington .. 1,869 90 23 86 31 15 13 10 5 3 Nelson-Marlborough 95 40 80 36 7 3 2 2 5 ] Canterbury .. ..2,520 199 2,431 194 174 30 141 16 24 14 West Coast .. .. 349 80 327 77 20 9 9 8 11 1 Otago .. .. 1,769 215 942 88 121 3 33 3 10 Southland .. .. 242 32 149 8 39 10 2 .. Totals .. .. 13,619 1,445 9,842 1,230 743 124 492 95 87 ~~28

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Table 2. —Showing Inspection of Premises engaged in selling or manufacturing Foodstuffs during the Year ended 31st December, 1939.

T. R. Ritchie, Director, Division of Public Hygiene.

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(Not inclusive of Inspections performed by Officers Employed by Local Authorities.) Inspections. Health District. N '™ ber ? f T dumber of l remises inspected auQ j 1 p remlse3 Instances Goods engaged in where Defects were "seized" manufacturing occurred. or "destroyed." Foodstuffs. North Auckland .. .. •• •• 426 97 Central Auckland .. .. • • • ■ 853 24 12 South Auckland 1,343 215 4 Thames-Tauranga .. .. • • ■ ■ 319 7 Taranaki .. .. ■ ■ • • • • 677 53 3 East Cape .. .. • • • • • • 866 230 4 Wellington - Hawke's Bay .. .. •• 2,244 393 Central Wellington .. .. • • • • 599 90 30 Nelson-Marlborough .. .. .. • • 635 113 Canterbury .. .. .. •• •• 1,017 59 .. West Coast .. .. .. . • • • 668 59 4 Otago 1,256 179 5 Southland .. .. .. •. • • 586 95 5 Totals 11,489 1,614 101

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PART lII.—SCHOOL HYGIENE. I have the honour to report on the work of the Division of School Hygiene for the year ended 31st March, 1940. Staff. At the present time the permanent staff consists of a Director, 15 School Medical Officers, and 4 Medical Officers who in their districts are appointed to act as Medical Officers of Health and School Medical Officers. The four School Medical Officers appointed from overseas have taken up duty as follows : Dr. Mavis Zane, Auckland ; Dr. Edna Mackenzie, Hamilton ; Dr. Fannie Hirst, Wellington ; and Dr. Jane Druker, Christchurch. In addition, Dr. Charles W. Parr was appointed in May to the School Medical Service, and he carried out school medical inspection duties in North Auckland until December ; he was in February again appointed to the North Auckland district. Figures relating to Work accomplished in 1939. The following summary serves to indicate the extent of work accomplished during the school period, February to December, 1939 :— Schools inspected—• Of roll under 100 .. .. .. .. .. 940 Of roll 100 to 500 .. .. .. .. .. 430 Of roll over 500 .. .. .. .. ~ 137 1,507 Children examined— Complete examinations .. .. .. .. 84,415 Partial examinations .. . . .. .. .. 39,670 124,085 Number of children notified as defective .. .. .. .. 44,091 Number of addresses to school-children .. .. .. .. 547 Number of parents interviewed .. .. .. .. .. 18,084 Number of lectures or addresses to parents .. .. .. .. 92 Summary of Complete Examinations. European. Maori. Number of children examined .. .. .. .. 73,751 5,715 Percentage found to have defects .. .. .. 52-69 65-81 Percentage with defects other than dental . . .. 30-33 31-51 Percentage of children showing evidence of— Subnormal nutrition .. .. .. .. 4-37 3-41 Pediculosis .. .. .. .. .. 0-31 4-39 Uncleanliness .. .. .. .. .. 0-72 1-82 Skin— Impetigo .. .. .. .. .. 0-57 2-75 Scabies .. .. .. .. .. 0-32 15-50 Ringworm .. .. .. .. .. 0-15 0-17 Other skin-diseases .. .. .. .. 0-93 0-45 Heart— Organic disease .. .. .. .. 0-38 0-35 Functional disturbance .. .. .. 0-66 1 ■ 14 Respiratory disease .. .. .. .. 0-62 2-22 Total physical deformities .. .. .. .. 6-60 5-00 Mouth— Deformities of jaw or palate .. .. .. 2-41 0-54 Dental caries .. .. .. .. 30-36 51-44 Extractions of permanent teeth .. .. 6-4-9 3-01 Fillings .. .. .. .. .. 59-20 20-09 Perfect sets of teeth .. .. .. .. 4-46 15-27 Nose and throat— Nasal obstruction .. .. .. .. 1-58 0-93 Enlarged tonsils .. .. . . . . 15-43 15-99 Enlarged glands .. .. .. .. .. 6-81 5-84 Goitre— All degrees .. .. .. .. .. 13-28 5-72 Incipient .. .. .. .. .. 10-61 5-25 Small .. .. .. .. .. 2-36 0-35 Medium .. .. .. .. .. 0-25 0-07 Large .. .. .. .. .. 0-06 0-05

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Summary of Complete Examinations—continued. Percentage of children showing evidence of —continued. Eye European. Maori. External eye disease .. .. .. .. 0-91 0-63 Total defective vision .. .. .. .. 4-34 1-57 Corrected .. .. .. .. .. 2-42 0-14 Uncorrected .. .. .. .. .. 1-92 1-43 Ear — Otorrhoea .. .. .. .. .. 0-18 0-44 Defective hearing .. . . . . .. 0-33 0-28 Defective speech .. .. .. .. .. 0-50 0-19 Mental— Feeble-mindedness .. .. .. .. 0-19 0-12 Epilepsy .. .. .. .. .. 0-03 Other nervous defects .. .. .. .. 0-11 Tuberculosis— Total .. .. .. .. .. 0-02 o'4o Pulmonary .. .. .. .. .. 0-01 0-24 Other tissues .. .. .. .. 0-01 0-16 School Medical Officers report that the general health of the children was good. There was no serious epidemic of infectious disease, and little time was lost on account of minor sickness. Kindergarten and Pre-school Children. Medical inspection is provided for all children attending kindergartens who have not their own medical advisers, and, in addition, School Medical Officers examine pre-school children whenever the opportunity offers. The defects found are similar to those found in primary-school children and afford evidence of the necessity of medical inspection for this group of children. Parents and teachers of kindergartens take a great interest in these medical examinations, and in most cases take advantage of the advice given. Dr. Anderson reports that it would be of great advantage if the dental clinic commenced operations at the kindergarten stage when the parents are more amenable. At one kindergarten of twenty-three children which Dr. Irwin examined in Southland, ten had perfect teeth ; she considers there is a good field for special observation with regard to milk-consumption, nutrition, and teeth at kindergartens. Dr. Rippin reports that all the five kindergartens in Dunedin were visited during 1939 ; there was an excellent response to invitations sent out to mothers, 75 per cent, of the mothers attending the examination to discuss the well-being of their children. Secondary Schools. School Medical Officers report that the stress of duties, including in many districts extensive diphtheria immunization, has interfered with the medical inspection of secondary schools. Officers who have had the opportunity of inspecting these schools refer to the amount of acne present in a large proportion of the pupils, while other defects differ in certain respects from those found in primary schools. For instance, the percentage found with enlarged tonsils is lower than that for primary schools, while the amount of defective vision is greater. Many schools pay special attention to posture, and a School Medical Officer reports that at one school in her district special drill classes are held for those children with postural defects and poor physique ; the classes have proved to be a great success, and the improvement each year has been most marked. Dr. Wilson reports that the health of secondary-school children appears to depend to a large extent upon the keenness of the teachers on the subject of health. In some secondary schools the children appear to be in good health with clear skins, abundant energy, and good nutrition. In other schools too large a percentage with marked acne is found, a certain amount of lassitude, and indifferent nutrition. When the principal of a secondary school is keen on physical education an improvement in the posture of the pupils is noticed and they appear to be more alert mentally and physically. The Department is again indebted to local practitioners for the medical inspection of the boys of the Hutt Valley High School. Native Schools. More and more Native schools are medically examined each year, and although the percentage of children found to be suffering from skin-disease still remains far in excess of the pakeha, all School Medical Officers pay tribute to the work of the district nurses in their endeavours to cope with this condition. On the whole, however, the results of the examination disclose that the majority of the Native children are in a satisfactory state of health. Dr. Parr spent six months in the North Auckland district and states that there is a strong contrast between the physique and general nutrition of the Native children in the schools up the East Coast, and those in the west and north. In the former the children are well nourished and of good physique. On the west, the younger children are well below the average '; many are anaemic, coughs and colds are very prevalent, and chest symptoms usual. When they reach the age of eleven or twelve years the change is notable ; they put on weight and develop a physique generally better than the pakeha of the same age. Dr. Zane examined 120 children attending Native schools and found the majority very clean, tidy, and free from scabies (due to the untiring efforts of the

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district nurses). On the whole their physique was very good, with good healthy complexions, bright alert eyes, and the children compared more than favourably with the pakeha children of the same districts. The few Maori children seen by Dr. Zane in the city and provincial town schools did not have the same good healthy physique as the country Maoris. Dr. Boyd (Nelson) reported that the Maori children whom he examined were very far ahead of the pakeha as regards posture, physique, and deportment; perfect jaw-formation, with teeth to match was noted. Dr. Davis (Gisborne) writes : " I would like to again commend the work of a great many of the Native-school teachers for the interest they display in the various health activities connected with the Native-school children. There is ample evidence in many of the schools of the interest and the amount of effort put in by some of the teachers along the lines of health teaching, and in attention to skin-diseases, &c. These schools contrast markedly with a very few where there is obviously very little endeavour to improve the state of cleanliness of the children. One of the things that has impressed me most in my work in the Native schools, however, is the high standard of cleanliness that has been achieved, a standard which reflects great credit on the teachers concerned." Medical Examination of Entrants to Teaching Profession. The following is a summary of the examination of 1,007 applicants for entrance to training college last year : — Number of applicants examined .. .. .. .. .. 1,007 Number with any defect of vision .. .. .. .. .. 157 Number wearing glasses .. .. .. .. .. .. 145 Number with defective hearing .. .. .. .. .. 7 Number with any past or present aural disease .. .. .. .. 14 Number with nose defect .. .. .. .. .. .. 9 Number with throat defect .. .. .. .. .. ... 32 Number with enlarged thyroid .. .. .. .. .. 130 Teeth— Number with any caries when seen .. .. .. .. 105 Number with one artificial plate .. .. .. .. .. 95 Number with upper and lower plates .. .. .. .. 44 Number with malocclusion .. .. .. .. .. .. 9 Number with any heart or lung condition .. .. .. .. 15 Number deferred for immediate treatment .. .. .. .. 143 Number considered as excellent .. .. .. .. .. 226 Number considered as average .. .. .. .. .. 656 Number considered as fair .. .. .. .. .. .. 86 Number accepted .. .. .. .. .. .. .. 954 Number deferred for further examination .. .. .. .. 30 Number rejected .. .. .. .. .. .. .. 23 It is recognized that, working with such a short staff as has been necessary during recent years, the important work of assisting to train teachers in health and hygiene has not received the attention it merits from our officers. We have not even been able to supplement with practical lectures or demonstrations the course on hygiene now given by the training-college staffs. It is the desire of this Department to have sufficient staff to allow of medical officers giving regularly each year a course of practical lectures on hygiene, general health questions, the commonest diseases found in schools, sanitation, ventilation, &c. We cannot expect young teachers to go into the schools and make health one of the most important subjects, and to work as many lessons as possible with health as the basis, if we do not give them the foundation for such lessons while they are still at training college. Nutrition. The nutrition of the majority of school-children in New Zealand can be regarded as satisfactory, but School Medical Officers advise that there are still a number who show evidence of subnormal nutrition. New Zealand has abundance of the best food in the world available to all; what some parents fail to realize is that children should be fed well and correctly each day, not just once or twice a week, and that as well as good plain food, well cooked and served at regular hours, they require fresh air and sunshine, adequate rest, and regular sleeping-hours. Too much stress cannot be laid on these last factors. It is again reported that the nutrition and physique of town children compare more than favourably with country children, especially children who, after travelling long distances to school, have to help with the daily work on the farm. The reports of the newly appointed School Medical Officers from overseas agree that with the good living-conditions in New Zealand all children should reach optimum nutrition. That this is not so is a fact to be deplored, but one which only education can remedy. It is essential, therefore, that in our schools the time devoted to hygiene and diet should have a prominent place in the curriculum. If the principle of a sound mind in a sound body is emphasized and j>ractised in the early years of life, it must result in a desire to continue this principle after school days. The following extracts are indicative of reports of all School Medical Officers :— Dr. Mulholland.—" In the course of the physical examination of normal school-children one has formed a mental picture of the nutritional standard for each age-group. The majority of children fall into the ' average nutrition ' group. The two classes which arrest one's attention are those children who are above and those who are below the norm. The fact that there is in this district a permanent

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health camp to which relays of 100 school-children go every six weeks is a proof of the existence of a certain amount of subnormal nutrition. It is interesting to note, however, that, although the necessity for this permanent health camp still exists, it is becoming more difficult to obtain the full quota each term. From this it is reasonable to infer that the nutrition of school-children is improving." Dr. Anderson (Napier). —" This important subject seems to be of constant interest to the average individual, and almost invariably there is the association of food with it, whereas we have learnt from constant observation that, although quality of food and inability to deal with it intelligently play a big part in the question of nutrition, it is the outside factors which form the overwhelming causes _of poor physique and lack of weight . . . Excessive brain work affects the child. We notice it with the secondary-school girls particularly, when they indulge too freely in outside social activities. In connection with this, it is worthy of note that children who enter boarding school invariably gain in weight and. general physique. I have in mind a nervous underweight child of poor physique, from an excellent country home ; we had given up all hope of physical improvement until he went to boarding school. During the first year he did nothing remarkable, although a general improvement was noticeable; but during the next twelve months the gained 111 lb. and grew 2f in." Dr. Irwin (Southland). —" While this continues to be satisfactory on the whole for Southland, it is to be regretted that I can still offer approximately two hundred names of children for selection by the Health Camp Committee. There should be no lack of money, but people often tend to consider luxuries essentials." Health Camps. Health camps continue to function and do good work in restoring delicate children to health. Camps were conducted last year at Auckland, Hamilton, Gisborne, Wanganui, Otaki, Nelson, Marlborough, Canterbury, Otago, and Southland, and approximately two thousand, children were benefited in this way. The care of such a large group of children calls for much organization, and health camp associations are to be congratulated on the results attained. Two camps functioned throughout the year —namely, Wellington (at Otaki) and Wanganui. One School Medical Officer states that the great improvement in physical and mental vitality of the children returning from the camp is always a striking example of the benefit to be derived from a simple routine which provides the facilities for health—namely, fresh air, sunshine, correct food, rest, and exercise. Not to be forgotten is the educational value of the camp not only to those who participate, but to those who are at home when the children return. Milk-in-schools Scheme. The milk-in-schools scheme continues to expand. While it has been reported that some children for whom milk is obviously needed decline the ration, the vast majority are benefiting in no small degree. Much of the success of the scheme is due to the teachers who are responsible for seeing that the children are instructed as to the value of milk and that they receive the ration at a regular hour each day. At the commencement of the scheme it was hoped to compare the weights of children at schools taking the milk ration with children at schools not yet within the scheme. This was not possible, however, owing to the fact that before many months had passed the majority of the schools acting as controls were receiving the ration. Also, it was found that the parents of children in the control schools made a point of giving their children extra milk at home because they were not benefiting in the same way as those receiving milk at school. School Medical Officers and teachers agree as to the improvement in physical well-being, alertness, and activity of the children taking the milk ration. Dr. Dawson (New Plymouth), commenting on the milk ration, states that before the institution of the scheme children who had come to school after an early breakfast made hea,vy inroads into their lunch at morning interval, with the result that they were short of food in the middle of the day ; as a result, quite a number were hungry and tired and were quite incapable of assimilating any knowledge during the last period of afternoon school. Now one notices that children who drink milk do not take any play lunch. Tuberculosis Contacts. The School Medical Service endeavours to keep under supervision all tuberculosis contacts. In Wellington there are 235 contacts under supervision. The children are seen at least once a year by the Chest Specialist; if necessary they are X-rayed. At the age of thirteen or fourteen they are all X-rayed. Occasionally parents refuse to allow their children to attend the Chest Clinic. Quite recently two cases have come under notice where for years opposition was met with ; finally when the children have reached adolescence the parents gave their consent —at this late stage T.B. lesions were detected. Incidents such as these should make us realize that there is still a good deal of prejudice and ignorance as to what these public health services exist for. Dr. Moir (Wanganui) reports that a routine X-ray examination of all contacts between four and twenty years is being undertaken, and where the results of X-ray justify it, arrangements are made for the case to be seen by the visiting tuberculosis officer. In Napier the nurses have continued the good work of keeping in touch with all tuberculosis contacts, and, where the parents co-operate, keeping a record of their growth period. Some contacts keep in touch even though they are working and away from school completely; these still keep up their visits to the Chest Specialist and report the findings to the nurse, which is very gratifying.

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The nurses in Auckland visit the homes of contacts regularly and keep charts of their height and weight and advise parents with regard to the hygiene of their homes, &c. Contacts are weighed and measured by the school nurses in the city schools in Southland, and an arrangement is being made with the Education Board for the redistribution of weighing-machines, enabling the teachers in the remote places to keep a record. In Dunedin Dr. Bippin reports that 237 contacts are kept under supervision. As far as possible parents or guardians of contacts are invited to school medical inspection. Contacts in Christchurch are under the supervision of the clinic attached to the public hospital, where the children attend periodically for examination. Dental Caries. Every opportunity has been taken by School Medical Officers to impress upon parents the importance of a healthy mouth, but dental caries remains one of the problems which cause much concern. The dental clinics are doing good work with the younger children, and where a school is attached to a dental clinic the children's mouths are clean until they reach the higher standards ; from then onwards deterioration is rapid, and in many cases the teeth are left unattended until full extraction is necessary. Diphtheria Immunization. Protection against diphtheria has been offered to parents in most of the North Island districts. Intensive campaigns were carried out by our medical officers, and many thousands of children have been rendered immune from this disease. In one or two districts, however, full advantage has not been taken of this offer, and there would appear to be a need for repeating the advice of the Medical Besearch Council of Great Britain that " Parents would be well advised to demand this prophylactic innoculation not only for their own children, but for all children. There seems no room for doubt that the general adoption of diphtheria prophylaxis would cause the virtual disappearance of the disease from the country. The family tragedies, the high public expense, and the waste of medical effort caused in Great Britain by diphtheria call for a united effort." Physical Education and Posture. School Medical Officers still report that a large percentage of the children suffer from faulty posture, and that although in some schools where the headmaster is keen extra time is devoted to the correction of this condition, in many cases no effort is made to train or instruct the children as to the necessity for good posture. In discussing this question, Dr. Phillipps (Auckland) states that " nearly all the children in the schools are round-shouldered. The carriage of the head is bad, the eyes being directed on the ground some few feet in front of the child instead of being directed straight forward. The whole attitude is one indicating a want of muscular tone. Undoubtedly the school curriculum, with its addiction to desk work, perpetuates, if it does not cause, the stooping attitude." With the appointment of additional physical instructors to the Education Department, however, an improvement can be expected. School Buildings and Sanitation. Much rebuilding and renovating of schools has taken place during recent years, and the following extract from the report of Dr. Gilberd (Whangarei) sums up the position in New Zealand as a whole " The year has been distinguished by great activity in these respects. Many new schools have been built and of a standard more in keeping with modern ideas ; others have been altered, and there is manifested a greater desire to provide in the school a standard of sanitation that will be carried as an object lesson back into the homes." Acknowledgment. The Division of School Hygiene wishes to express appreciation to the Education Department, Mental Hospitals Department, Education Boards, School Committees, and teachers for valuable co-operation. Elizabeth Gunn, Director, Division of School Hygiene.

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PART IV.—HOSPITALS. I have the honour to submit the annual report of the Division of Hospitals. The provision under the social-security legislation of hospital benefits, which came into force on Ist July, 1939, lias accentuated the shortage of hospital accommodation which has been evident for some years. That the majority of the Hospital Boards of the Dominion have made efforts to overcome this shortage of accommodation is shown by the extensive list of hospital buildings which have been either commenced or planned, and which has kept the Division very busy during the year. Fire-escapes.—The provision of adequate fire-escapes and fire-alarm systems has continued during the year and many institutions have now been satisfactorily equipped in this respect. Tuberculosis. —The necessity of providing more accommodation for tuberculosis has been discussed with those Boards in whose districts there is a large Maori population. The Boards concerned view the matter sympathetically, and it is hoped that during the coming year progress will be made in the erection of the necessary annexes. Hospital Building Activities. Southland Hospital Board. Kew Hospital.- The roof of this hospital was unfortunately damaged by fire on Ist August, 1939. Great credit is reflected on the staff by the manner in which the patients and equipment were saved, and the main hospital activities transferred to the Dee Street Hospital. The infirmary patients from the Dee Street Hospital were transferred to the old infirmary buildings, which had been closed for over two years. It was decided to reroof the building with " Fibrolite," concealed by a parapet. Opportunity was taken to strengthen the building. This work is now in progress. Tuberculosis Annexe. —This building was renovated and occupied during the year. A workshop was erected and extensions were made to the laundry building. Riverton Hospital. —Considerable improvements have been effected. A new laundry and mortuary have been completed. Vincent Hospital Board. The new hospital at Cromwell was occupied during the year. Improvements to the Clyde Hospital have been carried out. Waipiata Sanatorium Committee. —Additional nurses' bedrooms and other small buildings were finished during the year, and a house is in process of building for the Secretary. South Otago Hospital Board. Balclutha Hospital.—Additions to the Nurses' Home are being built, and plans have been prepared for a new children's ward, new stores and teaching blocks, and a new dispensary. Otago Hospital Board. Dunedin Hospital.—New X-ray equipment was purchased for Dunedin Hospital. A squash court was erected. Additions to the Nurses' Home at Dunedin Hospital are in hand. Land was purchased for future out-patients and massage departments. A gymnasium is being erected. Plans are under consideration to extend the X-ray Department, and build two new wards above it. Waitaki Hospital Board. Oamaru Hospital.—A Medical Superintendent's residence is being built. Plans have been agreed upon for two new awards, new massage, X-ray, out-patients, and operating theatre departments ; also a new boiler-house, laundry, and additions to the Nurses' Home. South Canterbury Hospital Board. Timaru Hospital.—A building was purchased as accommodation for nurses. Plans for a new kitchen have been agreed upon. New X-ray equipment has been purchased. Ashburton Hospital Board. A Medical Superintendent's residence is in course of erection. North Canterbury Hospital Board. Christchurch Hospital—Additions to the Nurses' Home are proceeding. New X-ray equipment was purchased for Christchurch Hospital and Cashmere Sanatorium. The final plans and specifications for the subsidiary hospital are being prepared. Additions were made to the Rangiora Hospital. The Kaiapoi Hospital was purchased and added to. Grey Hospital Board. Greymouth Hospital. —The tuberculosis block has been completed. Buller Hospital Board. Plans have been prepared for additions to the Kawatiri Hospital. Further consideration lias been given to plans for Nurses' Home, operating theatre, and other additions to the Westport Hospital.

4—H. 31.

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Nelson Hospital Board. Nelson Hospital—Plans are almost complete for additions to this hospital. Temporary accommodation for nurses has been built. Plans have been finalized for maternity hospitals at Takaka and Collingwood. Additions have been made to the Motueka Hospital. Marlborough Hospital Board. Additions to the Nurses Home and to the Holmdale Maternity Home are in process of erection : also alterations to the Wairau Hospital. Plans for an administration block and an additional ward block are under discussion. The rebuilding of the Picton Hospital is being considered. Wellington Hospital Board. An emergency ward of fifty beds has been erected at Wellington Hospital, and the childrens' operating theatre has been remodelled. A stores block and a new boiler-house are under construction. Piling and excavations have been carried out for a block of 127 nurses' beds and for the Centennial Hospital Block. New X-ray apparatus has been purchased. Plans have been prepared for a hospital at Hutt Valley, and for alterations to Wellington Hospital. Maternity accommodation has been provided at Hutt Valley. Palmerston North Hospital Board. Palmerston North Hospital.—An emergency ward is almost completed. Final plans are almost complete for the isolation block and for additions to the Nurses' Home. Awapuni Home.—Additions are being built at the Awapuni Home. Wairarapa Hospital Board. Masterton Hospital.—A swimming-bath has been erected. Alterations to wards and to the administration block are being made at the Masterton Hospital. Additional nurses' accommodation has been completed. Greytown Hospital—Alterations have been made to the theatre block and kitchen. Dannevirke Hospital Board. Dannevirlce Hospital.—New X-ray apparatus has been purchased. The new wards and administration block are almost completed. Additions were made to the boiler-house. Wanganui Hospital Board. Wanganui Hospital—Additions have been made to the massage department. New X-ray equipment has been purchased. Raetihi Hospital. Plans have been completed for additional wards and nurses' accommodation. Taranaki Hospital Board. New Plymouth Hospital.—Additions to the X-ray department, and alterations in order to provide adequate out-patients and house surgeons' accommodation are being completed Opunake Hospital.—Additions have been made to this hospital. Waipawa Hospital Board. Waipukurau Hospital.—Plans have been completed for new wards, additions to the Nurses' Home and extensions to the out-patients' department. New X-ray equipment has been purchased. Hawke's Bay Hospital Board. Hastings Hospital—A Medical Superintendent's residence and temporary accommodation for the nurses have been built, also alterations to the hospital. New X-ray equipment has been purchased. 1 Jans lor additional accommodation for tlie nursing staff are being prepared. Napier Hospital.—Plans have been agreed upon for new X-ray block, mortuary, teaching block and Nurses Home. An old building was renovated to accommodate chronic patients. Wairoa Hospital Board. Plans have been prepared for a new maternity hospital and for additions to the hospital and to the Nurses Home. 1 Cook Hospital Board. Extensions to the Nurses' Home are in course of erection. Alterations have been made to the hospital. A tuberculosis annexe is being planned. New boiler-house and laundry have been completed. Opotiki Hospital Board. Plans are m process of preparation for an extensive remodelling of Opotiki Hospital including increased accommodation and the provision of accommodation for tuberculosis cases.

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Bay of Plenty Hospital Board. Whakatane Hospital.—A Medical Superintendent's house, additions to Nurses' Home, and extensions to male ward have been completed. Plans are in course of preparation for extensions to maternity block. Tauranga Hospital Board. Tauranga Hospital.—Works contemplated are : Additions to staff dining-room, maternity annexe, tuberculosis annexe, additions to Nurses' Home, office block. Te Puke Hospital.—Additions to Nurses' Home are contemplated. Katikati. —Plans for a new maternity hospital at Katikati are being prepared. Thames Hospital Board. X-ray equipment has been purchased for Thames and Coromandel Hospitals. Additions to the Nurses' Home and the maternity home at Thames have been completed. Alterations at Coromandel Hospital have greatly improved the institution. Waikato Hospital Board. Waikato Hospital.—Various methods to provide more accommodation at this hospital are being reviewed by the Hospital Board. Matamata Hospital. —Additions are being made to this hospital. Auckland Hospital Board. Auckland Hospital.—-A new boiler has been purchased. Ward 2 has been converted to a casualty department. New diagnostic and therapy X-ray equipment has been ordered. Epsom Infirmary. —Plans are being prepared for extensive additions to the wards and Nurses' Home at the Infirmary. , Bay of Islands Hospital Board. Kawakawa Hospital.—Plans are under consideration for additional maternity accommodation. Kaipara Hospital Board. An emergency ward has been planned for Te Kopuru Hospital. Whangaroa Hospital Board. Sketch plans have been prepared for a new hospital at Kaeo. Mangonui Hospital Board. A boiler-house and new laundry are being erected at Kaitaia Hospital. Departmental Hospitals. St. Helens Hospital, Christchurch. —At present the Public Works Department is preparing the detailed working drawings and specifications for this institution, and as soon as these are completed it is hoped to call tenders for the work. Queen Mary Hospital, Hanmer. —Good progress has been made with the erection of the new male pavilion, and this should be ready for occupation in the very near future. R. A. Shore, Director, Division of Hospitals.

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PART V.—NURSING. I have the honour to present my annual report for the year ending 31st March, 1940. This year has been a particularly busy and difficult one. In the early months a great deal of work was involved in preparation for the introduction of the maternity and hospital benefits under the Social Security Act. During the same period the Nursing Division was in close consultation with the New Zealand Registered Nurses' Association concerning the formation of a Nurses' Union and in the preparations being made for a Nurses' Centennial Conference, to which it was planned to invite Australian delegates, but which later had to be abandoned. Early in the year two Councils were set up as sub-committees of the Medical Committee of the Organization for National Security—a Nursing Council consisting of the Director, Division of Nursing, as Chairman ; Miss Willis, Matron-in-Chief of the Army Nursing Service ; and Miss Banks, of Palmerston North Hospital, representing the public hospital Matrons, and a Voluntary Aid Council consisting of the Nursing Council with a representative of the New Zealand Red Cross Society and the Commandery of St. John. The work of these two Committees is to be responsible for the organization of registered nurses and the training and organization of voluntary aids in time of national emergency. In September, with the outbreak of war, the work of these two Committees became intensified. Two senior members of the Nursing Staff retired during the year—Miss R. Mirams, Nurse Inspector in Auckland for many years, retired in September, and Miss J. Moore, who was in charge of the postgraduate course, terminated her duties with the course in January, 1940; the Hon. the Minister has, however, approved of her continuing in office attached to the Nursing Division to assist with the increased duties attached to this Division. Miss F. Cameron returned from abroad, having completed a year's study of medical social work in Canada and the United States of America, in October, and at the end of the year was appointed as the second Nurse Instructor for the post-graduate course. Miss R. Patterson was also attached to the staff at Head Office to be responsible for the organization of refresher courses for obstetric nurses and the inspection of maternity-training schools. There has been a large number of transfers of staff. Five nurses who had leave on pay completed their post-graduate course ; five others were granted leave for the current year. Three members of the nursing staff have left on active service—Miss H. M. Scott, Nurse Inspector, Palmerston North ; Miss Hubbard, District Nurse, Opotiki; and Miss 0. Friis, Hanmer Springs. General Hospitals. The attached table sets out the position in regard to the nursing staffs of training-schools in relation to the occupied bed rate of the hospitals. As will be seen, the occupied bed rate of the hospitals has steadily risen. The effect of the hospital benefit available under the Social Security Act has been to further extend this rate. This has resulted in a further rise in the number of nurses required to staff these hospitals. For a time the demand was so great that it was difficult to maintain the standard of applicant, but partly because of better propaganda and partly no doubt on account of the war this position has been largely remedied. Forced by difficulties in regard to accommodation, several Hospital Boards have adopted the living-out principle for the registered nursing staff, until at Auckland Hospital about 90 per cent., and at Wellington Hospital 80 per cent., live out. Many other hospitals are using the same principle with registered nurses. The staffs generally are happy and contented and like the freedom this life gives them. One or two hospitals are attempting to introduce the case method of nursing in certain departments. This is a most important step forward, and deserves every encouragement. When hospitals are very crowded it will not be possible in every ward, but it might be introduced in certain departments. I am impressed by the fact that the majority of training-schools are not using the excellent material in their out-patient departments to the extent which they might, the tendency being to use registered staff so as to avoid changes. With the policy of centralization another important aspect of teaching— the instruction in dietetics, both theoretical and practical—will require watching to ensure that adequate attention is given to this subject. A. Daily Average Occupied Beds for all Training-schools. 31st December, 1932 .. .. .. .. .. .. 3,981-72 31st December, 1933 .. .. .. .. .. .. 4,059-30 31st March, 1935* .. .. .. .. .. .. 4,220-05 31st March, 1936 .. .. .. .. .. .. 4,467-41 31st March, 1937 .. .. .. . . .. .. 4,734-85 31st March, 1938 .. .. .. .. .. .. 4,911-26 31st March, 1939 .. .. .. .. .. .. 4,981-39 31st March, 1940 .. .. .. .. .. .. 5,331-80

* Statistics changed from calendar to financial year.

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B. Total Nursing Stuff for all Training-schools. 1932. 1933. 1934. 1935. 1936. 1937. 1938. 1939. Total nursing staff .. 1,769 1,967 2,116 2,264 2,442 2,534 2,710 3,028 Total pupil nurses on staff .. .. 1,257 1,412 1,502 1,640 1,803 1,849 1,985 2,219 Total registered nurses on staff .. 512 555 614 624 639 685 725 809 C. Total Number of Nurses Sitting and Passing State Examinations. 1932. 1933. 1934. 1935. 1936. 1937. 1938. 1939. Number sitting .. 385 448 403 354 380 478 455 490 Number passing .. 272 338 280 262 315 366 364 374

Showing (per 100 occupied beds) Particulars of Nursing Staff Employed at Training Schools as at 31st March, 1940.

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Obstetric Hospitals. Maternity benefits under the Social Security Act include free domiciliary and visiting nursing, free public hospital care, and largely subsidized private hospital care, as well as medical care. The scale of payments introduced has on the whole improved the position of the obstetrical nurse very considerably as far as private practice is concerned, and so should result in more nurses being inclined to practise obstetrics. On the other hand the new legislation is raising fresh problems in those trainingschools where the medical attention is limited to the teaching staff. It is essential that an adequate amount of clinical experience should be available in the training-schools for teaching purposes, or the whole quality of our training system will fail. Now that obstetrical nursing has become a service subsidized by the State it is essential that the standard of service should be maintained, and even raised. As a beginning it is proposed to hold a refresher course for obstetrical nurses in each health district annually. In the meantime these courses are optional, but it is questionable whether they should not be made compulsory for nurses whose practise is not of a high standard. The position in regard to the number of obstetric nurses passing the annual examination, and who are practising, is as follows : — Maternity Nurses. Registered Nurses. 1932. 1933. 1934. 1935. 1936. 1937. 1938. 1939. Number sitting .. 152 158 170 190 195 201 218 216 Number passed .. 143 148 108 180 189 193 207 212 Unregistered Nurses. 1932. 1933. 1934. 1935. 1936. 1937. 1938. 1939. Number sitting .. 35 43 33 34 43 36 46 43 Number passed .. 30 35 30 33 37 30 44 40 Mid wives. Registered Maternity Nurses who are also Registered Nurses. 1932. 1933. 1934. 1935. 1936. 1937. 1938. 1939. Number sitting .. 45 48 53 57 58 55 54 49 Number passed .. 39 44 47 53 56 54 52 49 Registered Maternity Nurses who are not Registered Nurses. 1932. 1933. 1934. 1935. 1936. 1937. 1938. 1939. Number sitting .. 14 14 18 14 9 19 11 17 Number passed .. 11 12 13 13 7 17 10 15 Public-health Nursing. At the beginning of 1939, forty additional district nurses and four additional Nurse Inspectors were appointed to the staff. It will be understood, therefore, that last year was a year of stabilization, inaugurating new staff and adjusting boundaries. Some areas are still too large, and require further subdivision, but the increase will enable much more intensive educational work to be achieved. Group health teaching has extended both amongst children and adults, particularly in Maori districts. Mention might be made of the women's institutes in the north, the school clinics in the East Coast district, and the Maori Women's Health League in the South Auckland district. In the South Island for the first time a definite effort has been made to break away from the specialized fields of work and introduce a more generalized programme, paying more attention to tuberculosis in all its forms. A family-record system has been introduced, and, though not in general operation, is being gradually extended. In addition, an analysed weekly work return for all district nurses is now in operation, which will assist supervising officers to check the way the work is developing. Tropical Nursing Service. Numerous changes have also taken place amongst nurses seconded for duty to one of the tropical stations during the year. There are now thirty-six New Zealand nurses in this service. Since the outbreak of war nurses are rather reluctant to accept these positions, hoping for opportunity for active service. It must be appreciated, though, that this is an essential service, and that in entering it nurses are assisting their country to care for those entrusted to its care. During the year Miss J. Flint, of Auckland St. Helens, succeeded Miss Becker as Matron of Apia Hospital ; Miss Riekman, of Central Auckland Health District, succeeded Miss McPhail at Rarotonga ; Miss L. Peirard returned from Aitutaki and was appointed Matron at Ranfurly; her successor has not yet taken up duty. Miss Hawkes returned to Niue for a second term. Post-graduate Course. At the termination of the 1939 course it became necessary to vacate the rooms at the Wellington Hospital where the post-graduate course has always been conducted, owing to the expansion of the hospital services. Great difficulty was experienced in finding suitable accommodation, but finally a temporary arrangement was made by taking over the ministerial residence in Molesworth Street. One of the future developments will be a proper school; as the course has extended its activities this has become more than ever necessary.

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This year the courses given include one for the preparation of medical social workers, a service which is in its infancy in New Zealand, but which is very necessary, particularly with the extension of social legislation. So as to include further field-work the course has been extended by another month, and it has been decided to advise intending applicants that students will not be accepted over thirty-five years of age, unless exceptional circumstances exist. In February the first reunion and refresher course for students was held ; over seventy nurses attended, and had a very happy and profitable day. Opportunity was taken by the nurses holding their diploma to give Miss Moore, on retirement, a token of their deep appreciation of what Miss Moore has done for nursing education in New Zealand. With Miss Moore's retirement, Miss R. Bridges has taken over the course in hospital administration and teaching, and Miss F. Cameron that of public-health nursing and medical social work. Nursing Education. The study of nursing procedures was continued. The previous method of questionnaire followed by the publication of a prepared technique was followed, further attention being given to children's nursing and the last offices for the dead. A series of suggested topics for film strips for teaching purposes were also drawn up, and it is proposed to arrange for the preparation of these strips in conjunction with the New Zealand Registered Nurses' Association, for sale amongst the training-schools. An essay competition entitled " Personal Hygiene in the Life of the Nurse " was won by Hokitika Hospital. Health of Nursing Staffs. The international study concerning health statistics among nursing staffs concluded its investigations with the year 1938. This report is not yet published, but there is no doubt it aroused a very considerable interest in this important subject. The Department intends to pursue the subject in a slightly different form with the object of obtaining more exact information concerning our own conditions. The Nursing Service and the National Emergency. In view of the fact that for the past three years New Zealand has experienced a shortage of registered nurses, with the outbreak of war it became necessary to control the recruitment of nurses to a much greater extent to ensure an adequate nursing service for New Zealand, the maintenance of our present standard of training, and at the same time provide a carefully selected and competent personnel for the New Zealand Army Nursing Service. The following recommendations from the Nursing Council have been approved by the Government:— (1) No permits will be given for registered New Zealand nurses to travel beyond New Zealand unless grave personal reasons exist: (2) No Matron of a training-school or senior member of the nursing profession, holding a key position, will be released for active service unless an understudy has been trained to fill her position : (3) All nurses in the employ of the Government or a Hospital Board, proceeding on active service, are to be given indefinite leave, and the Government or Hospital Board will be responsible for the nurses' superannuation contributions while on active service : (4) Applicants for the N.Z.A.N.S. are considered by the Nursing Council and graded according to the nursing services of the country—i.e., Hospital Boards, private hospitals, private nursing, Government Departments, Plunket Society. In calling up nurses, consideration according to the number of nurses in each service and each district is to be given in assessing the allocation : (5) A scheme for giving a short training in hospital for voluntary aids was inaugurated for those who had certificates in home nursing, first aid, and hygiene, from either the New Zealand Red Cross Society or the Commandery of St. John : (6) A register of registered nurses not in active practice but who would be willing to assist, in times of emergency, either in their own district or elsewhere, was inaugurated in each health district with the co-operation of the New Zealand Registered Nurses Association. In this way it is hoped to ensure that the national service in New Zealand is maintained, and yet a well-qualified group of Sisters may be provided for the New Zealand Army Nursing Service. New Legislation. In October, 1939, an amendment to the Nurses and Midwives Registration Act was passed which inaugurated several important changes : — (a) Provision was made for the training and examination of nursing aids according to the scheme outlined in last year's report, with the creation of a special register for these aids : (b) Mental hospitals were graded as B Grade Training Schools for nurses, and now come under the supervision of the Nurses and Midwives Registration Board as far as their teaching is concerned. Mental nurses in future will sit for the State Preliminary Examination, and on completion of their three years' mental training will be given credit for one year three months if they wish to continue with their general training :

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(c) An annual practising certificate has been introduced for all registered nurses, midwives, maternity nurses, and nursing aids in the future. This has long been a great need to ensure an accurate register, and should be of great assistance during the national emergency : (d) The disciplinary powers of the Registration Board were increased to permit the Board to suspend a nurse from the register, or to fine a nurse for offences under the Act. Previously the Board had only power to warn a nurse, or remove her from the register entirely. Under any of these conditions a nurse has the right of appeal before a Judge of the Supreme Court: (e) Provision was made for the training of male nurses if required : (/) Provision was made that the uniform of a registered nurse or nursing aid might be prescribed if so desired. The Nurses and Midwives Registration Board. The Nurses and Midwives Registration Board met four times during the year, and give the usual consideration to reports concerning the work carried out in the various training-schools, the conduct and results of the State examination, registration of nurses, reciprocity with other countries, numerous reports concerning nurses with broken periods of training, in addition to cases where disciplinary action was necessary. At the end of the year Mr. W. Wallace, who had been a member of the Board for nine yea,rs, representing the Hospital Boards, and Miss B. Campbell, of New Plymouth, both retired after giving very valuable service to the Board. Mr. Wallace was replaced by Mr. Dove, Chairman of the Otago Hospital Board and Chairman of the Hospital Boards Association, and Miss Campbell by Miss Nutsey, Matron of Auckland Hospital. In conclusion, with so many meetings in Wellington, it has not been possible to give so much time to travelling, although, with the assistance of Miss Moore and Miss Bridges, every training-school and district office was visited. I realize that I owe a debt of gratitude to all the members of the staff for a great deal of assistance during a particularly difficult year. In the same way the helpful co-operation of the Hospital Boards and their executive staffs, the voluntary organizations, and the New Zealand Registered Nurses' Association has been very much appreciated. M. I. Lambie, Director, Division of Nursing.

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PART YL—PRIVATE HOSPITALS AND MATERNAL WELFARE. I have the honour to present my report for the year 1939, including a survey of the existing maternity services, European and Maori maternal welfare, and licensed medical and surgical and convalescent hospitals. SECTION I.—MATERNITY HOSPITALS AND OTHER MATERNITY SERVICES. The hospital maternity benefits provided by the Social Security Act which have been in operation since 15th May, 1939, have provided a degree of economic security to the licensees of private maternity hospitals and obstetric nurses that they have never enjoyed before. They have also provided patients with free hospital attendance in all public hospitals and very much cheaper attendance in even the more luxurious private hospitals and in the unlicensed one-bed homes conducted by registered midwives or maternity nurses. The result has been an increase in the number of private maternity hospitals from 189 in 1938 to 196 in 1939. Some Hospital Boards who previously were unwilling to provide maternity hospitals are now doing so, with a resulting increase in the number of beds in public maternity hospitals from 524 in 1938 to 565 in 1939. Additions to both class of hospitals are still being provided. In spite of the increase in the number of beds the available ones are being booked up to their full capacity, and in some districts there is a demand that cannot be fully satisfied. It is anticipated that as the Maori population recognizes the benefits of being attended in hospitals, which they could not previously afford but which are now free to them, there will be further demands on hospital beds. Endeavours are being made by the Department to point out to Hospital Boards the necessity for meeting this demand. The four State (St. Helens) Hospitals now provide 90 beds, these having been increased by the addition of 5 beds to the St. Helens Hospital at Invercargill. All of these beds are required for training midwives, of whom 64 successfully passed through their training in these hospitals, and, in addition, 32 maternity nurses were trained and registered. Twenty-three of the seventy-two public maternity hospitals are approved by the Nurses and Midwives Registration Board as training-schools for maternity nurses, of whom 220 trained in these hospitals were placed on the register last year. There is still a shortage of practising maternity nurses which is giving great concern to the Nurses and Midwives Registration Board. Further particulars on this important maternity service will be found in the report of the Director of the Division of Nursing. Table I on page 34 gives in tabular form the returns of three groups of hospitals—Group I consists of four State St. Helens Hospitals, Group II of the 72 public hospitals, and Group 111 the 196 private hospitals, while Table II gives in greater detail the results of the St. Helens Hospitals. The systems of attendance in the three groups of hospitals differ materially. The private hospitals (Group III) do not receive the same proportion of foreseen abnormalities as do the other two groups, consequently results are not strictly comparable. In the private hospitals (Group III) practically all patients are attended by the doctor of their own selection, these hospitals are licensed under the provisions of the Hospitals and Charitable Institutions Act, 1926, and are inspected regularly by Medical Officers of Health and their Nurse Inspectors under the direction of the Director of Maternal Welfare, who acts in conjunction with the Medical Officer of Health and his subordinate officers. In St. Helens Hospitals (Group I) the system of attendance is as follows :— All are given ante-natal attention by the medical staff and midwives specially trained in antenatal care. Normal cases are attended by the midwife staff alone, who administer anaesthetics, analgesic, and amnesic drugs according to the direction of the Medical Officers of each hospital. Patients exhibiting any abnormal conditions during pregnancy or parturition are attended by the medical staff, and all cases who can be persuaded to report receive post-natal examination by the medical staff between the sixth and ninth week following delivery. In the public hospitals (Group . II) the system of ante-natal and post-natal attention is the same, but the majority of patients arc delivered by doctors either on the staff or in private practice with the assistance of the midwife or maternity nurse, the doctor taking full responsibility for normal and abnormal cases, instead of the midwife for the normal and doctor for the abnormal case. The hospitals in Group I and II are inspected periodically by the Director, Division of Nursing, and the Director of Maternal Welfare. Accessory to these services are the practising midwives and maternity nurses, the majority of whom attend their patients in the nurse's own residence, control of these being provided by the regulations under the Nurses and Midwives Registration Act.

5—H. 31.

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Causes of Death. Group I.—St. Helens Hospitals : Toxaemia of pregnancy, 1 ; placenta praevia, 1 ; post-partum haemorrhage, 1 ; non-puerperal coronary embolism, 1. non-^erperil'T^ HoapitaU --$ e V sis > 7 ; P ost -P artum haemorrhage, 7 ; placenta praevia, 1 ; other puerperal haemorrhages, 3 ; eclampsia, 3 other toxaemias of pregnancy, 3; embolism, 2 ; obstetric shock, 4 ; Group 111 Private Hospitals : Sepsis, 6; post-partum haemorrhage, 3 ; placenta previa, 3 ; other puerperal haemorrhages, 1; eclampsia, 2 ; other toxaemias of pregnancy, 2; embolism 1- thrombosis 1accident of pregnancy, 1 ; obstetric shock, 5 ; non-puerperal, 2. r s j> » 1 > a.

Table I.—Statistics of Maternity Hospitals.

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I /dSed. I III i ill Number of Operations. Hemorrhages. | ° o| p^ te If | a 4 H § = 5 : 5 3* Infants bom transferred ° ~ 3 § £ Versions «- " . Caesarean g ® | ® ® © g go toother gee ; 5 2 Is M M I 211 i* ■ ° I -lllljal 2. H^' 8 - K < i I I II | 1 |IS| 3 go! I! i i 1 3-g 2| * I I || o|!& II I g| 5* S|j =1 gi fl § S I 5 <5 go5® "3 a ®J2 & g £ -f© fl 2 t : 28 : S "So | |> m S? J"! P<° ~ I | 8S I | !«-» I I--3 |« j 2 I | 3° |= | ! ! nHi |K I |M IS* SASigSa s* II I g u ! : \ ■ b >*■ u *. H , g M | h oa a fk g H I ft I ft pq «! q £ § 8 *' HelenS 4 90 139 1,990 115 1,964 8 87 5 18 3 1 10 6 '• 38 14 16 23 6 3 33 31 30 2 14 1 3 1 4 Pe coSn a ement S t0tal 4 ' 43 °' 2& °' 92 °' 15 °'° 5 °' 51 °' 31 " 193 °' 71 °' 81 X " 17 0 310-153 168 l ' 58 153 0-10 0-710-051 0-153 0-0510-204 Gl hospitals '* 8 ' 548 8, °° 7 376 8,383 87 63? 10 2 ® " 25 66 24 2 367 35 45 130 30 23 152 148 105 38 200 11 30 4 34 tered by Hospital Boards Pe coSn a ements t0tal 7 ' 6 ° °' 12 °' 31 °' 2 ° °' 3 ° °' 79 °' 29 °'° 2 4 ' 38 °' 42 °' 54 1-55 °- 36 <>-274 1-81 1-77 1-25 0-45 2-390-1310-358 0-480-406 Group III: Private 1961,025 52816,54515,665 79416,459 701,948 84 28 19 58 111 18 .. 644 42 52 177 45 16 229 292 143 100 151 12 27 1 28 Hospitals P^W g r^ P l t0tal JJ. 1184 °' 51 017 °' 12 °' 35 °" 67 O" 11 -- 3-91 0-26 0-32 1-07 0-270-097 1-39 1-77 0-87 0-61 0-920-0730-1640-0060-170 T °tals .. .. 2721,6801,299 27,083 25,521 1,28526,806 1652,672 99 72 39 84 187 48 91 113 330 81 42~414 "In 24 60 6 66 P !"nSih t0ta ' " " 9 97 °' 37 °' 27 °' 15 °' 31 0 ' 70 0-18 °' 01 3 ' 91 0-34 0-42 1,23 0-300-157 1-54 1-76 1-04 0-52 1 -360-090 0-2240-022 0-246

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Table II.—St. Helens Hospitals Statistics, 1939.

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0 'o 53 §)_ SR T3 o £ 5p ~ .2 — j ! | I | T ° tais - ilj |_3 I I I &** A. Intern Department. Total deliveries .. .. •• 746 547 385 286 1,964 Primiparse .. .. .. • • 244 187 102 76 609 31*01 Miltiparso .. .. .. • • 502 360 283 210 1,355 68*99 Presentations and positions— Vertex normal rotation .. .. 706 509 358 229 1,802 91*75 Occipitio posterior (persistent) .. .. 17 16 12 14 59 3*00 Face .. .. .. •• 2 1 1 2 6 0*31 Brow .. .. .. .. •• 3 .. .. 3 0*15 Breech .. .. .. .. 21 26 24 13 84 4*28 Transverse Twins (sets) .. .. .. ■ ■ 4 8 10 5 27 1 * 37 Complications of pregnancy — Hyperemesis .. .. .. •• 2 3 3 8 0*41 Hydramnios .. .. .. .. 2 2 4 4 12 0*61 Pre-eclamptic toxaemia .. .. 29 12 14 14 69 3*51 Eclampsia .. .. .. •• 3 2 1 .. 6 0*31 Nephritic toxaemia .. .. .. .. 7 1 .. 8 0*41 Haemorrhages — Unavoidable (placenta prsevia) .. .. 4 2 8 2 16 0*81 Accidental, external .. .. .. 7 1 2 4 14 0*71 Accidental, internal Post-partum, atonic .. .. .. 9 6 6 1 22 1*12 Post-partum, traumatic .. .. • • 1 • • • • 1 Lacerations of genital-tract — PerinEeum .. .. .. . • 97 89 67 31 284 14*46 Cervix .. .. .. •• •• 1 2 .. 3 0*15 Uterus Contracted pelvis, inlet .. .. .. 1 2 4 .. 7 0*36 Contracted pelvis, outlet .. .. 4 .. 1 .. 5 0 • 25 Prolapse of cord .. .. •• 1 ■■ 2 .. 3 0*15 Complications of puerperium— Sepsis, local .. .. .. .. 6 1 8 6 21 1 * 07 Sepsis, general .. .. .. 1 • • • • • • 1 0' Pulmonary embolism .. .. .. .. 2 .. .. 2 0*10 Insanity .. .. • • • • 1 • • • • • • 1 0-05 Crural phlegmasia, venous .. .. 1 • • • • • • 1 0*05 Crural phlegmasia, lymphatic Mastitis .. 9 6 .. .. 15 0*76 Operations— Induction of labour .. .. .. 32 22 11 17 82 4*18 Episiotomy .. .. .. .. 23 9 6 6 44 2 • 24 Complications— Impacted shoulders .. .. .. 2 .. 1 .. 3 0*15 Suture of perineal lacerations — Incomplete .. .. • • • • 4 .. .. .. 4 0 • 20 Complete .. .. .. • • 93 89 67 31 280 14*26 Forceps .. . • • • • • 40 27 14 6 87 4 • 43 Version, external .. .. .. 1 1 3 .. 5 0*25 Version, internal .. .. ■ ■ 1 9 5 3 18 0*92 Version, combined .. .. .. •• 1 1 1 3 0*15 Manual removal of placenta .. .. 3 4 2 1 10 0*51 Cesarean section .. .. .. 2 1 3 .. 6 0*31 Craniotomy Cleidotomy Decapitation Morbidity .. .. .. • • 47 44 24 9 124 6 • 31 Mortality .. .. .. •• 1 2 .. 1 4 0*20 Infant statistics — Total births .. 750 555 395 286 1,986 101*12 Premature — Alive .. .. .. •• 30 45 20 8 103 5*24 Dead — Recent .. .. .. 1 6 6 3 16 0*81 Macerated .. . > •• 1 •• •• 2 3 0*15 Putrid ..

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Table II.—St. Helens Hospitals Statistics—continued.

Ante-natal Clinics. Table 111 gives the returns from 50 free ante-natal clinics, 4 of which are connected to St. Helens Hospitals, 31 with other public maternity hospitals, 10 conducted by nurses of the Plunket Society, and 5_ by licensees of the large private hospitals. The system of attendance at these clinics in most cases is that all normal cases are examined twice during pregnancy by a medical officer and monthly, or more often if necessary, by the nurses in charge of the clinic, most of whom are specially experienced m this work. Ail cases of abnormality suspected or diagnosed by the nurses are referred for medical examination, either by the medical officers of the hospital or, in the case of Plunket or private clinic s, by their own medical attendants. There has been difficulty in some of the hospitals in ensuring that the patients shall all receive medical attention, irrespective of whether they show abnormalities or not. Arrangements that this should be done have been made in most cases. From every point of view this is necessary, particularly in those cases where the patient is attended during labour by a midwife only, who is authorized to administer araesthetics to the obstetrical degree. It is obviously necessary that no patient should have an anaesthetic so administered who has not been examined by a doctor and certified as fit for it. Such an act by a nurse is a breach of the Nurses and Midwives Regulations. Ihe majority of patients receive ante-natal attention from their own doctors, with or without the additional service given by clinics. This service is part of the usual medical service in relation to maternity benefits under the Social Security Act, and may or may not be supplemented by attendance at the clinics. It is hoped that complete co-operation between the clinics and the private practitioners will be obtained. Such a combination should provide an ideal service.

Table III.—Ante-natal Clinics.

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i i | i ill | | I § Totals. jj£g O S3 .2 © O »-~H rj © M t> S-l O ±_ & a_ ___ A. Intern Department—continued. Infant statistics—continued. Full term— live •• •• .. .. 694 510 361 269 1,834 93-38 Dead— Recent .. .. .. .. 12 10 2 2 26 1-32 Macerated .. .. .. 8 .. 6 2 16 0-81 Putrid Children born alive who died in hospital .. 8 12 12 1 33 1-68 Total born dead or died in hospital .. 30 28 26 10 94 4-79 B. Extern Department. Total attended .. .. .. .. 38 9 52 n no Primiparso Multiparas .. .. .. .. 38 9 52 11 no 100-00 3 .. 3 2-73 MorbidityMortality C. Ante-natal Clinic. First visits— Primiparsc .. .. .. .. 286 195 113 76 670 Multipara; 548 413 328 221 1,510 Return visits 4,312 2,841 2,662 1,061 10,876 Outside visits .. .. .. .. 125 490 676 3 1 294

Average Year " JggS* New Cases. Keturn Visits. A J n tLs. ES&£Returns. per Patient. 1925 .. .. .. 16 2,289 7,816 10,105 4-41 20 3,238 12,554 15,792 4-88 20 3,919 15,406 19,325 4-93 1928 21 5,050 20,740 25,790 5-11 1929 24 5,177 17,555 22,732 4-39 1930 25 6,027 22,078 28,105 4-66 1931 •• .. .. 29 6,306 22,869 29,175 4-63 1932 .. .. .. 31 5,882 22,594 28,476 4-84 1933 33 5,978 25,794 29,772 4-98 ;934 .. .. 34 6,191 24,929 31,120 5-03 •• •• 37 6,725 26,662 33,389 4-96 1936 . ; . .. .. 39 7,069 29,103 36,272 5-13 193? 38 6,746 28,769 35,515 5-28 938 .. .. .. 48 8,221 33,808 42,029 5-11 1939 •• .. .. 50 8,728 34,618 43,400 4-94

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Maternity Services in General Medical and Surgical Hospitals. Such a sparsely populated country as New Zealand necessitates the use of general medical and surgical hospitals under the Hospital Boards for a very considerable number of the graver emergencies of pregnancy, as well as for the treatment of puerperal sepsis following childbirth, and for abortions. Private medical and surgical hospitals are also used for these cases requiring surgical intervention, such as Csesarean Section. The use of the general wards of these hospitals in those places which have not a maternity annexe attached to them is the most unsatisfactory feature of the service. Wellington Public Hospital has for some time had attached to its staff obstetrical specialists, and has a labour ward, but the maternity patients, having been confined under aseptic conditions in this ward, are then transferred to the general wards, where it is difficult to ensure that they are not nursed by nurses who also attend septic surgical cases. This is unsatisfactory. Auckland General Hospital has now established a small and complete unit, consisting of a labour ward and a lying-in ward, sufficient to deal with the abnormalities admitted generally for emergency treatment. This unit has a complete staff of midwives and maternity nurses and is under the charge of a visiting specialist. Christchurch, while having specialists attached to their staff, has no separate obstetrical unit which would be required to give the best results. Neither Invercargill or New Plymouth have either obstetrical specialists in charge or a special ward, though both require organized units capable of dealing with obstetrical emergencies which are at present admitted to the general ward. It is trusted that the position in Christchurch will be rectified by the provision of a new St. Helens Hospital, which will be large enough and have the staff to cope with all obstetrical emergencies. Table IV shows the number and nature of cases admitted to these hospitals, and the very high death rate of 7-47 per cent, given in Table V shows the very dangerous nature of the cases admitted, and the necessity for making the very best possible provisions for their treatment in these hospitals until all these cases are provided for. Even under present conditions better results might be obtained if there were better anticipation of the emergencies that arise, and they were referred earlier for treatment.

Table IV. —Maternity Cases admitted to General Hospitals.

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1936. 1937. 1938. 1939. Cases. I Deaths. Cases. Deaths. Cases. Deaths. Cases. Deaths. For ante-natal treatment only 24 . . 21 .. 62 1 41 Admitted before delivery— For ante-natal treatment and delivery 29 13 10 1 25 2 For emergency cases without compli- 20 .. 27 .. 52 1 60 cations For obstructed labour .. .. 109 3 117 7 131 4 153 5 Failed forceps .. .. .... .. .. .. 7 1 5 1 For accidental haemorrhage 27 4 28 2 25 .. 31 3 For placenta prsevia .. 23 2 23 1 41 4 45 5 For eclampsia .. .. 29 3 25 2 19 20 2 For puerperal toxaemia without 41 4- 57 4 59 3 64 6 eclampsia For other conditions .. 37 3 65 14 76 5 65 11 Totals .. .. .. 315 19 365 30 510 20 468 35 Method of deliveryNatural .. .. .. 133 7 146 11 173 10 197 8 Instrumental .. .. 16 .. 23 .. 24 .. 43 6 Cesarean Section — Primary .. .. ..127 4 151 10 181 6 190 11 Secondary to failed forceps ..1 .. 3 2 3 1 2 Induction of labour .. 17 1 34 3 35 .. 25 3 Other operations .. .. .. 4 .. 5 1 2 .. 7 3 Undelivered .. .. ..7 7 3 3 2 2 4 4 Totals .. .. .. 510 20 365 30 315 19 468 35 Admitted after delivery— For eclampsia and toxaemia 7 1 9 6 12 2 13 3 For post-partum haemorrhage, shock, 6 .. 7 7 14 3 25 3 and embolism For puerperal pyrexia and sepsis 72 9 112 9 141 9 148 7 For other conditions associated with 112 5 133 7 169 5 195 3 parturition Totals .. .. .. 197 15 261 29 336 19 381 16

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Table V.

Obstetrical Research. The year 1939 saw the appointment by the Medical Research Council of a Committee of Obstetrical Research. Dr. F. 0. Bennett was appointed Obstetrical Research Officer and began his work with a statistical inquiry into the incidence of toxaemias of pregnancy in New Zealand. His report fills 72 typewritten pages and was based on the examination of 7,286 charts drawn from forty-seven hospitals and Plunket ante-natal clinics which have for many years past provided free antenatal care to the women of New Zealand. Space does not permit of even a summary of the report. One hundred and three copies have already been distributed and others will be sent, as long as the limited supply is available, to those specially interested on application to the Department. At the suggestion of the Obstetric Officer, arrangements have already been made to make alterations in the Department's ante-natal charts used in these clinics to ensure greater accuracy and more specific information of certain points. Research in the fimiliary or hereditary incidence of toxaemias of pregnancy and other aspects of the problem is proceeding. In addition to this organized research by the Obstetrical Research Committee the medical staff of St. Helens Hospitals have done very useful work by paying special attention to the best methods of relieving pain of normal labour and the institution of systematic maternity exercises. Dr. Chapman, of St. Helens Hospital, Wellington, continues to report favourably on the use of Dr. Small's apparatus for the administration of ether by the patient herself under the supervision of the nursing staff. Dr. Paterson, St. Helens Hospital, Auckland, has used nitrous oxide and air and nitrous oxide and oxygen to a limited extent, but states that the patients prefer the Murphy's inhaler. Dr. Averill, St. Helens Hospital, Christchurch, relies on the Junker chloroform method, which, if manipulated by the patient herself, is regarded as safe, but if used otherwise it is only safe in the hands of a skilled anaesthetist. He reports that in many instances the patient cannot manipulate it, and it is administered by the midwife. I regard this as unsafe, unless in the hands or under the supervision of a skilled medical anaeathetist. Dr. Mac Gibbon, St. Helens Hospital, Invercargill, relies chiefly on the selfadministration of chloroform by the Murphy inhaler in conjunction with various hypnotic and amnesic drugs. The use of systematic exercises based on the Margaret Morris system first introduced into the St. Helens Hospital, Wellington, by Dr. Chapman has again proved so advantageous that the Director, Division of Nursing, has arranged for as many midwives as possible to be taught to act as instructors in these exercises. To this end Professor Dawson, in conjunction with Dr. Sylvia Chapman and others, have drawn up a system of exercises which will be adopted as standard for the training of nurses and midwives in New Zealand. Dr. Chapman, the Medical Superintendent, reports as the result of these exercises a forceps rate of 1-8 per cent, in the 322 patients practising the exercises last year, as compared with a forceps rate of 9-76 per cent, for the 215 patients who did not take advantage of them. This confirms the result reported by her for the previous year and may be regarded as showing that these exercises have a very definite usefulness in obstetrics. Section II. —Maternal Mortality and Morbidity. PART I.—EUROPEAN. The increase in the number of live births from 27,249 in 1938 to 28,433 in 1939 caused an increase in the birth-rate from 17-93 to 18-73. In the same period the still-births increased from 743 to 900, causing an increase in the still-birth rate per 1,000 live births from 27-3 to 30-27. Over the same period the infant deaths in the first fortnight of life, which should be taken into consideration in considering any return of still-births as the factors causing them are almost identical, were 600 (rate, 21-44) in 1938, and 585 (rate, 19-67) in 1939. The total maternal deaths due to causes attributed to pregnancy or childbirth, other than deaths from septic abortion, in 1939 were 85, giving a death-rate of 2-95, compared with 2-97 for the previous year. A comparable rate for England and Wales for 1938, the last year available, was 2-80. This fall in the total maternal mortality was contributed to by a slight fall in the deaths from toxaemia and eclampsia, producing the lowest rate since 1937. These reductions were offset by a very considerable rise in the deaths grouped under the heading " Accidents of labour.'' In this group there were 42 deaths, giving a rate of 1-46, the highest total and the highest rate since 1927. Four of the 42 deaths in the group classed as due to " Accidents of labour " followed delivery by Caesarean Section. Table VI gives the numbers and rates under the different classification groups for each year from 1927 to 1939, and in the same table are included death-rates from septic abortion, which, for obvious reasons, are, as in England and other countries, considered separately, as they are not influenced by measures taken to prevent the incidence of sepsis following childbirth. There as a 33-per-cent. reduction in the number of deaths, and a corresponding reduction in the death-rate from this cause. The information in this table is displayed in the graph on page 39, and Table VII gives particulars in greater detail for 1939 under each classification group.

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Year. 1932. 1933. 1934. 1935. 1936. 1937. 1938. 1939. _____ I Number of cases .. .. 193 277 269 316 365 510 468 Death-rate, per cent. .. 11-19 8-28 5-78 8-18 5-69 6-47 3-92 7-47

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PUERPERAL MORTALITY. Showing the Death-rate per 1,000 Live Births since 1927.

39

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Table VI.—Puerperal Deaths and Death-rate per 1,000 Live Births.

Table VII. —Peurperal Mortality, 1939, Showing Number of Deaths and their relation to Live Births.

Puerperal Sepsis following Childbirth. During the past year 147 cases of sepsis were notified, of which. 131 were in Europeans and 16 in Maoris. Of these, 120 were the subject of inquiry by questionnaires, supplemented, where possible, by personal inquiry. Of the 120 cases 111 occurred in Europeans and 9in Maoris. The returns show that only in 8 cases among the Europeans was faulty technique reported, and 4 out of the 9 investigated Maori cases were nursed under conditions in which asepsis was impossible. In my opinion, the number of cases returned as due to faulty technique is underestimated. There are still a number of nurses whose training, if any, occurred before the teaching of asepsis and by whom the principles of asepsis are not fully appreciated. Medical practitioners might with advantage give more supervision in such cases.

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1927. 1928. 1929. 1930. 1931. 1932. 1933. 1934. 1935. 1930. 1637. 1938. I 1939. ; I Puerperal sepsis following child- No. 56 42 30 27 18 13 14 17 8 9 14 21 16 birth Rate 2-01 1-64 1-12 1-01 0-68 0-52 0-58 0-70 0-33 0-36 0-54 0-77 0-55 Accidents of labour (hsemorr- No. 35 30 39 36 31 30 29 19 24 25 12 29 42 hages, shock, embolism, and Rate 1-26 M0 1-46 1-34 1 16 1-21 1 19 0-78 I 00 1-01 0-46 1 06 1-46 accidents of childbirth not otherwise defined) Toxaemia and eclampsia .. No. 27 40 34 36 38 23 29 30 34 30 35 29 24 Rate 0-97 1-47 1-27 1-34 1-43 0'92 1-19 1-24 1-42 1-20 1-35 1-06 0-83 Accidents of pregnancy (non- No. 5 8 7 7 11 9 10 10 12 14 9 2 3 septic abortion and ectopic Rate 0-18 0'29 0'26 0-26 0-41 0-36 0-41 0-41 0-50 0-57 0-34 0-07 0-1.1 gestation) Total maternal deaths (exclud- No. 123 120 110 106 98 75 82 76 78 78 72 81 85 ing septic abortion) Rate 4-41 4-42 4-11 3-96 3-68 3-02 3-37 3-12 3-25 3'14 2-69 2-97 2-95 Septic abortion — Married women .. .. No. ,, 1( , / 26 26 24 16 29 17 13 16 20 11 Single women .. .. No. J \ 4 3 2 10 13 6 1 7 10 9 Totals .. .. 14 14 19 30 29 26 26 42 23 14 23 30 20 Rate .. . • _ 0-50 0-51 0-71 1-12 1-09 1-04 1-07 1-73 0-96 0-56 0-92 1-10 0-69

Number Death Rate of per 1,000 Deaths. Live Births. Puerperal sepsis following childbirth .. .. .. .. .. 16 0-55 Accidents of labour — . Placenta prsevia .. .. ■ • • ■ • ■ 10 Post-partum hemorrhage .. .. .. .. 11 Puerperal embolism .. .. .. .. 9 Other accidents of childbirth — Shock or syncope following— Ceesarean Section .. .. .. •. 11 Obstetric shock and heart-failure .. ..10^12 Ruptured uterus .. .. .. .. 1J 42 1-46 Toxaemias of pregnancy — Eclampsia .. • • • • • • • • 12 j Puerperal toxaemia .. .. •. • • • • ® 1 24 Hyperemesis gravidarum .. .. .. .. 2 j Acute yellow atrophy of liver .. .. .. 1J 24 0-83 Accidents of pregnancy — (a) Abortion (non-septic) .. .. .. • • 2 (b) Ectopic gestation .. .. ■■ 1 •• Total maternal deaths (excluding septic abortion) . . .. .. 85 2-95 Septic abortion — (а) Married women .. .. •• •• •• H (б) Single women . . . . ■ ■ • • • ■ • • • • 9 20 0-69

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The following facts concerning the deaths from sepsis following childbirth are worthy of consideration. In 1935 and 1936 the deaths were 8 and 9, and the rates 0-33 and 036 per 1,000 live births respectively. In 1937 the deaths rose to 14? and in 1938 to 21, and the rates per thousand to 0-54 and 0-77 respectively. In 1939, the year under consideration, an insignificant drop in the number of deaths to 16 brought the rate down to 0-55. It is interesting to note that during the period of thig rise in the death-rate from sepsis the use of the sulphonamide group of drugs came into extensive use, and this might have been expected to reduce the death rate, if not the incidence rate. An examination of the reports on all these cases in 1937, 1938, and 1939 shows that, while the incidence rate of sepsis rose, the case-fatality rate rose to a much greater extent, and that for that period approximately 88 per cent, of all cases were known to have been treated with sulphonamides. It is probable that a higher percentage were so treated, as some of the reports merely stated " routine treatment." It appears probable that this rise in the death-rate in excess of the rise in the incidence rate may have been due to the wrongful use of sulphonamides producing agranulocytosis. A recent letter to the Lancet from the pen of Leonard Colebrook, dated 15th July, 1939, increases one's suspicions that this may have been the case. This matter has been brought to the notice of the Obstetrical Society, to which I extend my thanks for taking action to draw the attention of their members to the possible danger. Inquiry again reveals that manual removal of the placenta was the outstanding cause of sepsis. This method of delivery occurred in 24 out of the 120 cases investigated, giving a sepsis incidence rate of 20 per cent.., as against 0-7 per cent, in the 26,806 confinementsjconducted in maternity hospitals. Three of these 24 cases following manual removal of the placenta died. Caesarean Section. All cases of Caesarean Section are reported to the Department, and Table VIII gives the results of 203 such cases. The report shows that 0-69 per thousand of the total confinements were delivered by this method, as compared with 0-73, 0-59, 0-64, 0-59, 0-53, and 0-44 in the six preceding years. The case mortality for the mothers was 6-40, as compared with 4-96 in 1938 and 7-64 in 1937, and that for infants was 18-23, as compared with 14-85 in 1938 and 21-65 in 1937. The table groups the cases according to the reasons given for operation, but I am not convinced that there is any sound reason for dividing the cases into obstruction from contracted pelvis, and cases that are returned as merely obstructed labour. In many cases returned as contracted pelvis the measurements were not given.

Table VIII. —Caesarean Sections.

fill . 31.

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£ Number of § Deaths. Group. Reason for Operation __ Cause of Deaths of Mothers. lis a | 3 3^0 & m a I Contracted pelvis— 1 para .. .. 32 3 1 Syncope. 2 para .. .. .. 21 3 para .. .. .. 1 5 para and over and not stated 6 Total .. 60 3 1 II Obstructed labour— 1 para . . . . 52 1 1 Pulmonary embolism. 2 para .. . . 13 3 3 para .. .. .. 5 1 7 para .. .. .. 1 13 para . . . . .. 1 1 1 Peritonitis. Multipara . . 3 1 I Ruptured uterus. Total .. 75 7 3 Of the above 75 cases, 4 followed failed forceps, all recovered. III Placenta prasvia— 1 para .. .. .. 14 5 2 One from sepsis, one post-partum haemorrhage. 2 para .. .. 12 4 1 Sepsis. 3 para . . . . 2 1 5 para .. . . . . 2 .. 1 Pulmonary embolism. Not stated .. 2 Total .. .. 32 10 4 IV Accidental haemorrhage — 1 para .. .. .. 4 3 2 para .. . . 3 2 3 para . . .. .. 1 4 para . . . . . . 1 1 Total , . .. 9 6

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Table VIII—continued.

PART lI.—MAORI. The following table gives the Maori maternal mortality rate on the same lines as Table VI for Europeans. The reason for giving these returns separately is that up to the present a large majority of the Maoris are delivered by Native methods, which must be regarded as extremely crude, and the conditions under which the confinements are conducted in Maori whares preclude any possibility of carrying out asepsis efficiently. Now that the maternity benefits under the Social Security Act are available it may be expected that much better results will be obtained owing to the fact that more Maoris will enter hospitals, the cost of which in the past was quite beyond their means.

Table IX.—Showing the Maori Maternal Mortality by Causes for the Nine Years 1930-39.

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& Number of j5 Deaths. a „ Reason given for Operation and "g „ „ „ woup Parity u Cause of Deaths of Mothers. s i § I I i I V Eclampsia— 1 para .. .. .. 5 2 1 Eclampsia. Not stated .. .. 11 1 Eclampsia. Total .. .. 6 3 2 VI Pre-eclamptic toxaemia— 1 para .. .. .. 7 6 1 Toxaomia complicated by placenta prsevia and post-partum hasmorrhago. 2 para .. .. .. 4 1 3 para .. .. .. 1 12 para .. .. .. 1 Total .. 13 7 1 VII Other conditions— Heart-disease (congenital)— 2 para .. .. .. 1 Tuberculosis— 1 para and 9 para .. 2 .. 1 Seven-month pregnancy and advanced tuberculosis. Subarachnoid haemorrhage— 5 para .. .. .. 1 Acute mania— 7 para .. .. .. 1 1 1 Six-month pregnancy. Only reason given : " Previous delivery by Cesarean Section " — 2 para .. .. .. 3 Total .. 8 1 2 Total cases .. .. 203 37 13

1930. 1931. 1932. 1933. 1934. 1935. 1936. 1937. 1938. 1939. Cause of Death. — ■ > No. Rate. No. Rato. No. Rate. No. Rate. No. Rate. No. Rate. No. Rate. No.| Rate. No. Rate. No.l Rate J _ I _ Puerperal sepsis following 5 2-35 5 2-16 5 1-82 7 2-37 3 1-01 7 2 15 6 1-65 4 1-01 6 1-62 3 0'73 childbirth Accidents of labour (hajmorr- 12 5-65 9 3-89 14 5-10 14 4-75 8 2-68 10 3-07 12 3-31 13 3-27 10 2-70 12 2-92 hage, thrombosis, phlegmasia, embolism, and following childbirth not otherwise defined) Toxaemia, albuminaria, and 1 0-36 1 0-34 .. .. 1 0-30 .. .. I 0-25 2 0-54 2 0-49 eclampsia Accidents of pregnancy .. 3 1-41 2 0-87 1 0-36 .. .. 4 1-34 3 0-92 .. .. 5 1-26 2 0-54 Total maternal causes 20 9-42 10 6-92 21 7-65 22 7'46 15 5-03 21 6-46 18 4-90 23 5-79 20 5-41 19 403~ (excluding septic abortion) Septio abortion .. 2 0-68 3 1 01 3 0 02 2 0-55 3 0-70 ~~ ~~(h49~ — . , ■ " ___

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PART lII.—COMBINED EUROPEAN AND MAORI MATERNAL MORTALITY. The separate statistics for Maori and pakeha, whose conditions in obstetrical practice are so entirely different, is necessary for one's own information and for the purpose of comparing our European maternal-mortality rate with that of Europeans and Maoris. For comparison with such countries as the United States of America, which has a large population living under similar conditions to the Maori, I have combined the maternal deaths in both races for which the rate is 3-15 per 1,000 live births. SECTION lII.—PRIVATE MEDICAL AND SURGICAL HOSPITALS. The following table shows the number of licensed medical and surgical hospitals ; mixed medical, surgical, and maternity hospitals ; and licensed chronic medical and convalescent hospitals. Eight of the smaller medical and surgical hospitals have ceased to function. The number of hospitals from 50 to JlB beds remains the same, with an increased bed capacity of 394, and one additional medical and surgical hospital of between 20 and 35 beds has been established. The number of beds in this group of hospitals has increased from 379 to 395. It may be noted with satisfaction that the mixed medical, surgical, and maternity hospitals, both public and private, which it was proved in 1929 were an unsatisfactory feature of our maternity service owing to the excessive amount of puerperal sepsis occurring in them, are now, by the exclusion of all septic surgical cases from those hospitals not having separate maternity staffs, giving a safe and satisfactory service. The operation of the hospital benefits provided by the Social Security Act has given rise to an increase in the medical and convalescent hospitals from 18 to 34, and of the beds available from 132 to 262. These hospitals are largely occupied by elderly chronic cases whose condition demands a greater degree of skilled attention than can be given in the ordinary boardinghouse but do not require the same degree of skilled attention as is necessary for more acute cases. They are, without any doubt, proving a great boon to people suffering from chronic diseases, particularly those due to senility. All these hospitals are regularly inspected by the inspecting officers of the Department, and co-operation between them and the licensee has been most helpful in maintaining a reasonably high standard of efficiency.

Table X.—Private Medical and Surgical Hospitals.

Acknowledgment. I again wish to acknowledge the very helpful co-operation of the New Zealand Obstetrical Society and its very cordial relations with the Department. I have already mentioned their co-operation in instituting an inquiry into the possible influence of the sulphonamide drugs upon the results in the treatment of puerperal sepsis. T have also to express my sincere thanks to the many voluntary associations, too numerous to mention, who had been of the greatest assistance in providing various amenities such as libraries, infants' layettes, and many other comforts contributing to the physical welfare and mental ease of mothers entering maternity hospitals and who are for the time being cut off from their families, for whom some of these societies provide reliable housekeeper service during the mother's stay in hospital. T. L. Paget, Director of Maternal Welfare.

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Classification by Number of Beds. Hospitals Total Beds. Private Medical and Surgical Hospitals. 50 to 118 beds .. .. .. .. 4 3!)4 20 to 35 beds .. .. .. .. .. 16 395 10 to 19 beds .. .. .. .. .. 31 425 5 to 9 beds .. .. .. .. .. 19 140 Under 5 .. .. .. .. .. 4 13 1,367 Private Mixed Medical, Surgical, and Maternity Hospitals. 35 148 1,515 Medical and Convalescent Hospitals. I 34 262

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PART VII. —DENTAL^HYGrIENE. I have the honour to submit the following report on the work of the Dental Division for the year ended 31st March, 1940. On account of war conditions the report is being made as brief as possible, and it does little more than record the main features of the year's work. School Dental Service : Progress of Expansion Programme. The expansion of the School Dental Service in accordance with the decision made in December, 1935, has been pursued vigorously during the year under review, and unless this programme is seriously retarded by the indirect results of the war situation the aim to make the service available to all primary schools in the Dominion by the end of 1941 should be realized. The demand for the establishment of school dental clinics still exceeds the supply of dental nurses. This is a satisfactory position, because if expansion is to continue without interruption, the supply of clinics ready for occupation must be a stage ahead of the supply of school dental nurses, and the provision of clinics requires the financial co-operation of the local dental committees. As the system approaches completion, the next stage, the extension of treatment to Standard VI, will be undertaken, and the further extension to post-primary schools will follow in due course. Reference was made in the last annual report to the early completion of the new Dominion Training School for Dental Nurses (in which is incorporated the Wellington Dental Clinic). This building has not been completed as soon as was expected. At the date of this report, however (31st March, 1940), arrangements had been made for the new training-school to be opened in May, 1940. Its opening will mark a new era in the work of the School Dental Service. The expansion of the field organization was further advanced by the appointment to field positions of 60 dental nurses who completed their training during 1939. Twenty-eight dental nurses became available for the field in April, 1939, and they were allocated as under: — To open new clinics . . .. . . .. .. . . . . 14 To reinforce existing clinics with a view to extending to additional schools . . 4 To fill vacancies, and in reserve . . .. .. .. .. 10 In October, 1939, a further 32 nurses completed their training and were allocated as under: — To open new clinics .. .. .. .. .. .. .. 4 To reinforce existing clinics with a view to extending to additional schools .. 13 To fill vacancies, and in reserve .. .. .. .. .. 15 Staff of Dental Division. On the 31st March, 1940, the professional staff of the Division, disposed as under, numbered 422. Of the 156 student dental nurses shown below, 36 had completed their training and were about to be transferred to districts and a further 80 had been appointed for entry to the training-school during 1940.

School Dental Service : Summary op Activities for the Past Year. The statistical section of this report shows that steady progress has been made in the period under review. The total number of operations shows a substantial increase over the previous year— namely, 912,370, as against 826,598 for 1938-39. The number of patients under treatment at the end of 1939 was 101,701, as against 94,261 in 1938. New school dental clinics were established during the year at 18 centres —namely, Balmoral, Darfield, Cheviot, Clydevale, Kumara, Luinsden, Meadowbank, Newmarket, Okaihau, Orepuki, Oxford, Parnell, Putaruru, Riverton, Spreydon, St. Heliers, Tolaga Bay, Tuatapere.

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Dental Trained Center Scho°t S * nd ? 1 f _ 4 , Officers. Nurses. £ enta] £ ontal £ ental Total - Nurses. Nurses. Nurses. Director .. .. .. .. 1 .. . . . , ., 1 Principal Dental Officer .. .. .. 1 .. .. . . .. 1 Principal, Wellington Dental Clinic .. 1 .. .. .. .. 1 Senior Dental Officers— (a) In districts .. .. .. 5 .. .. .. .. 5 (b) In training-school .. .. .. 1 .. .. .. „. X Dental officers— (а) In districts .. .. .. 5 .. .. .. .. 5 (б) In training-school .. .. .. 7 .. .. .. .. 7 Trained nurses — (а) Matron, Wellington Dental Clinic .. .. 1 .. .. .. 1 (б) Home Sisters, Hostels .. .. .. 2 .. .. .. 2 Senior dental nurses— (a) In districts .. .. .. .. .. 3 .. .. 3 (b) In training-school .. .. .. .. .. 7 .. .. 7 School dental nurses .. .. .. .. .. .. 232 .. 232 Student dental nurses .. .. .. .. .. .. .. 156 156 21 3 10 232 156 422

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In addition to these new centres, the following existing centres were reinforced by the appointment of additional staff: Alexandra, Birkenhead, Ellerslie, Henderson, Invercai'gill, Sandringham, Wliangarci Country. Forty-two new clinics have been authorized at centres which were not served before, and eight existing centres are to be reorganized in the immediate future, and their scope extended by the appointment of additional staff. Details of these are given in another section of this report. To facilitate the control of the ever-increasing number of clinics, the dental districts have been further reorganized by including the Taranaki Health District in the Wellington Dental District, instead of in the South Auckland Dental District as it was originally. The Principal Dental Officer, in addition to his duties at Head Office, retains control in the meantime of a small district comprising the Manawatu, Hutt Valley, and Marlborough areas. This has been designated, for the present, the " Inner Wellington District." Statistics. Operations performed in the field and in the training-school from Ist January to 31st December, 1939 :— Fillings— In permanent teeth .. .. .. .. .. 281,104 In deciduous teeth .. .. .. .. .. 334, 410 ——- 615,514 Extractions — In permanent teeth .. . . . . . . . . 2,954 In deciduous teeth .. .. .. .. .. 73,039 — 75,993 The following figures illustrate the progress made during the last 10 years : —

Total number of operations since the inception of the service, 8,463,189. Ratio of Extractions to Filling,s. The number of teeth extracted as unsaveable as compared with the number of fillings performed shows a small increase on this occasion, to the extent of 0-4 extractions per 100 fillings. This is accountable for by the number of new clinics opened, and the corresponding increase in the number of new entrants, as the latter invariably require a certain number of extractions. The figure for the year under review is 12-3 extractions per 100 fillings. The following table shows the ratio of extractions to fillings since the inception of the service

The above figures include both permanent and deciduous teeth. For permanent teeth alone the ratio is 1-05 extractions per 100 fillings.

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Number of Schools ' Number of Children 1 ,,, , , „ , ( Year. ' under Systematic ! receiving Systematic ! °,? u ,"' er ° Treatment.. ! Treatment. Operations. _ __ j jy— 1930 .. .. .. .. 930 67,652 ! 463,204 1931 .. .. .. .. 1,180 68,995 562,759 1932 .. .. .. 1,297 72,584 i 619,390 1933 .. .. .. .. 1,430 78,391 623,625 1934 .. .. .. .. 1,551 83,433 626,878 1935 .. .. .. 1,590 84,738 674,374 1936 .. .. .. .. 1,629 89,803 725,609 1937 .. .. .. .. 1,568 89,483 759,873 1938 .. .. .. .. 1,620 94,261 826,598 1939 .. .. .. .. 1,749 101,701 912,370

Fillings. Extractions. Rat *° : ?"j. ons 6 per Hundred Killings, 1921-22 .. .. .. 13,047 14,939 114-5 1922-23 .. .. .. 24,603 25,436 103-3 1923-24 .. .. .. .. 47,610 37,978 79-7 1924-25 .. .. .. .. 59,322 43,181 72-6 1925-26 .. .. .. 61,506 41,339 67-2 1926-27 .. .. .. .. 84,723 53,232 62-8 1927-28 .. .. .. 116,916 66,523 56-8 1928-29 .. .. .. .. 146,354 76,555 52-3 1929-30 .. .. .. .. 190,934 71,128 37-2 1930-31 .. .. .. .. 258,546 75,973 25-5 1931-32 .. .. .. .. 334,827 80,389 24-0 1932-33 .. .. .. .. 382,389 74,633 19-5 1933-34 .. .. .. .. 397,437 69,208 17-4 1934-35 .. .. .. .. 399,560 70,207 17-5 1935-36 .. .. .. .. 450,727 72,782 16-1 1936-37 .. .. .. .. 498,121 72,088 14-6 1937-38 .. .. .. .. 535,441 68,832 12-9 1938-39 .. .. .. .. 571,199 67,972 11-9 1939-40 .. .. .. .. 615,514 75,993 12-3

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New Treatment Centres. At 31st March, 1940, arrangements were well in hand for the establishment of school dental clinics at 42 new centres, and for the reinforcing of the staff at eight of the existing centres in order to enable extension to additional schools to be carried out. These centres are shown hereunder :— (1) New Centres.—Akaroa ; Boulcott, Lower Hutt; Dominion Road, Auckland; Elmwood ; Frankton ; Hamilton West; High Street, Dunedin ; Hikurangi: Invercargill South ; Kaeo ; Kaikorai; Kaikohe ; Kawhia ; Kaitaia ; Kerikeri; Kinohaku ; Kohimarama ; Lake Rotoiti; Maungaturoto ; Mangawai: Mangonui; Moana ; Newton Central ; Newton West; Omarumutu ; Otira ; Owairaka ; Paraparaumu ; Point Chevalier ; Raukokore ; Riccarton ; Reporoa ; Ruatahuna ; St. Andrews ; Te Kaha ; Tokomaru Bay ; Timaru South ; Tuai ; Waipu ; Waiuku ; Whakatane. (2) Existing Centres to be reinforced. —Cambridge ; Matamata ; Otahuhu ; Otorohanga ; Pukekohe ; Rangiora ; Rcefton ; Tauranga. Training of Dental Nurses. Dr. J. B. Bibby, Principal of the Wellington Dental Clinic, reports as follows on the training of dental nurses and the work of the clinic : — " (1) Staff. —In addition to the Principal, the training staff consists of eight dental officers, a matron, and seven senior dental nurses. In view of the further increase in the number of student dental nurses it was necessary again to augment the staff of dental surgeon instructors by appointing further trained dental nurses in a temporary capacity as Dental Nurse Instructors. " (2) Student Denial Nurses (as at 31st March, 1940) :— " In second year of training — " First group (sixteenth draft) and second group (fifteenth draft) .. 44 " Second group (sixteenth draft) .. .. .. . . .. 40 " In first year of training— " First group (seventeenth draft).. .. .. .. .. 37 " Second group (seventeenth draft) .. .. .. .. 35 " The year has seen still further increases in the number of student dental nurses. Of the total number of 75 appointed in 1939, 39 commenced training in April and the second group of 36 took up duty in October. The total number of nurses now in training is 156. " (3) Annexe. —As was indicated last year, to get more efficient working an endeavour has been made to station certain members of the staff permanently at the annexe, and certain sections of the training of both first- and second-year students are still being concentrated upon in this building. The loss of time by the instructional staff in transit between the two institutions will become more marked when the Whitmore Street clinic is transferred to the new building in Willis Street, and it may become necessary to reorganize the disposition of the staff and limit training in the annexe to the senior classes oniy. " (4) Examinations. —(a) It was necessary to hold two final examinations during the year. The first one in September, 1939, was for the second group of the fifteenth draft. Of the 30 candidates, 28 were successful in passing, and 2 were retained for a further six months' training. The second, final examination was held in March, 1940, for the first group of the sixteenth draft. All this group of 41 were successful in passing, and the majority are now in field clinics. " The external examiners on these two occasions were respectively Dr. W. S. Seed, of Christchurch (September, 1939), and Mr. A. IT. Weir, of Christchurch (March, 1940). " (b) Primary examinations were also held for the first and second groups of the seventeenth draft, the first being in September, 1939, and the second in March, 1940. The details are shown below : —

"The examiners were —First group : Dr. M. A. Champtaloup and Dr. S. L. Mulholland, second group : Dr. 8. L. Mulholland and Dr. F. Hirst. " (5) Course of Training.—The re-adjusted syllabus consequent upon the introduction of two drafts a year has been followed with minor variation, and reduction has been made in the length of the histology and the materia medica courses, whilst other subjects are also under review. " (6) Hostels for Student Dental Nurses.- The Department's hostel ' The Mansions,' Ghuznee Street, Wellington, has continued to function very satisfactorily under the control of Miss E. Pengelly. The Friends' Hostel under the control of Miss E. Searell is also giving good service, and the Department is again indebted to the Society of Friends for the continuance of the arrangement whereby student dental nurses are so well catered for. To meet the further increase in the number of student dental nurses it was found necessary to add an annexe to the recently acquired hostel in Hobson Street. Credit is again due to Miss Hooper, who supervised the whole of the renovations and furnishings of this building, and to Mrs. Wood, who is now in charge of the institution.

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- j Candidates. PassecL Failed ' j Kemarks. First group .. 37 37 Nil Second group 31 28 3 Three failed one paper; will sit a special examination in June.

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" (7) Statistical:— " (i) Attendances and Operations: Attendances recorded and operations performed in the Wellington Dental Clinic for the years 1937-38 to 1939-40 are shown below :— Attendances. Fillings. Extractions. Other Operations. " 1937-38 .. 47,238 31,014 3,141 31,931 " 1938-39 .. 52,997 42,419 3,894 33,894 " 1939-40 .. 62,544 37,264 2,850 41,100 (Decrease) (Decrease) "Increase since last 9,547 5,155 1,044 7,206 year " Total increase since 33,956 21,516 1,406 23,531 1936-37 "Total attendances recorded and operations performed to 31st, March, 1940: — Attendances. Fillings. Extractions. Other Operations. 615,437 412,747 79,258 355,754 " (ii) The number of patients under treatment at 31st March, 1940, 7082. " The number of admissions for the year is as follows : — " New patients commenced .. .. .. .. .. 915 " Transferred from other centres .. . . .. .. ~ 107 "Total .. .. .. .. .. .. 1,022 " The total loss of patients during the year — " Patients reaching the maximum age for treatment . . . . . . 165 " Patients transferred to other centres . . . . .. . . 112 " Patients whose treatment has elapsed through failure to attend .. 365 " Total .. ..... .. .. .. 642 " The net increase of patients under treatment is therefore 380, compared with 1,723 for the previous year. " (iii) Waiting List: The number of names on the waiting list as at 31st March for the last three years is as follows: 1937, 3,398; 1938, 1,095; 1939, 229; 1940, .1,092. " During this year 915 new patients commenced treatment, thus completely eliminating the names standing at 31st March, 1939. Of the 1,092 now waiting, none have been listed for more than six months, but the number of applications is steadily increasing. " During the past twelve months the smooth running of the training programme has been made more difficult in that certain members have been required to give much time to matters in connection with the new clinic, thus throwing extra stress on those required to take extra duties. All members of the staff have responded well. " In conclusion, I would also like to express my thanks to all members of the staff, who by their loyal co-operation have maintained the efficiency of the training-school and dental clinic ; to the Principal and officers of the Teachers' Training College, and to the Director and officers of other Divisions of the Department who have assisted in various ways in the course of training, and finally to those members of the dental profession who continue to co-operate and assist with the work of the Wellington Dental Clinic." Dental Health Education. Mention was made in the last annual report of this Division of' the time and instruction devoted during the period of training to the study of dental health education and dietetic principles, and the instruction given in methods of disseminating the principles advocated by the Department. In this connection a notable forward step lias been made by the Department in devising a uniform teaching for all officers, of whatever branch of the Department, who undertake health teaching. This should do much to clear up misunderstandings and ensure that a common front is presented to the public on the important subject of diet and nutrition. With the steady increase in the staff of the Dental Division it should be possible in the near future for more intensive educational efforts to be made on the part of all dental nurses, and increasing attention will be devoted to this essential aspect of the work of the School Dental Service. During the year under review the educational activities carried out numbered 2,461, exclusive of chair-side instruction, which is carried out as a routine procedure in conjunction with dental treatment. This figure represents an increase of over one thousand on the previous year's figure. There is still great need of a wider appreciation among parents and children, and, indeed, among the whole population, of the value of sound and healthy teeth in childhood, adolescence, and adult life. Sir George Newman, formerly Chief Medical Officer of the British Ministry of Health, has quoted a report from one of the " approved societies " under the national health insurance scheme, in which it is declared that " neglect of teeth trouble is the cause of quite half of the ill health found among the industrial classes." The results of dental health teaching are encouraging as far as the children are concerned. Unfortunately, it is the parents who are lagging behind, and it is they who, in the end, have it in their power to control the situation.

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Addresses to Training-college Students. Arrangements whereby Senior Dental Officers of the Department give instruction on the operation of the School Dental Service to students of the Teachers' Training Colleges in each of the four centres were put into effect during the yea,r. It is confidently expected that this plan will result in the close co-operation which already exists between the two services being still further increased. Dental Treatment of Native Schools. Strenuous efforts on the part of school dental nurses, district health nurses, teachers, and committees in Maori Districts have resulted in only a relatively small proportion of the children attending Native schools being brought under treatment, and the problem of the indigent Maori parent and the apathy of the Maori people in general towards dental treatment are providing a serious obstacle to the progress of the School Dental Service in these districts. The service is available for Native schools on the same financial basis as it is for pakeha schools, but there is a disinclination in many Native districts for the people to avail themselves of the Service under the present conditions. Research. Mention was made in the last annual report of this Division of a survey being conducted by Mr. A. D. Brice, 8.D.5., of this Department, under the auspices of the Dental Committee of the Medical Research Council, with a view to ascertaining the factors associated with dental caries in the Dominion. Owing to the war it was found necessary to postpone this work in the meantime, and further investigation has been deferred until a more favourable time. Acknowledgments. The opportunity is again taken of expressing the thanks of the Department to the personnel of Dental Clinic Committees, to teachers, and to Education Boards and their staffs, and also to all others who in various ways have rendered invaluable assistance in the carrying-on of the work of the School Dental Service. The staff of the Division has continued to give good service throughout the year, and I wish to express my keen appreciation of the loyal and efficient service which they have rendered. J. Ll. Saunders, Director, Division of Dental Hygiene.

Centres at which School Dental Clinics were established as at 31st March, 1940.

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Main Treatment Centres. Authorized Sub-bases. J | Main Treatment Centres. ! Authorized Sub-bases. A ucMand District.. Avondale, Auckland .. Blockhouse Bay. Ngatea .. .. Kaihere, Kerepeehi, Tunia, Balmoral, Auckland .. .. Waitakaruru. Beresford Street, Auckland .. Okaihau Birkenhead .. .. .. Onehunga Cornwall Park, Auckland .. Otahuhu Dargaville .. .. Ruawai, Te Kopuru. Paeroa Devonpoi't .. . . • . Papalcura Ellerslie, Auckland .. Howick. Parnell, Auckland Epsom, Auckland .. .. Ponsonby, Auckland Gladstone Road, Auckland .. Pukekohe Grey Lynn, Auckland .. . . Rawene Helensville . . . . Huapai. St. Heliers, Auckland Henderson .. .. Glen Eden. Sandringham, Auckland .. ICawakawa .. .. .. Takapuna Manurewa . . .. ■ • Tauranga Maungawhau, Auckland .. .. Te Puke Meadowbank, Auckland . . .. Thames .. .. Coromandel, Mercury Bay. Mount Albert, Auckland .. .. Tuakau Mount Eden, Auckland . . . . Waihi . . .. . . Tairua, Katikati. Mount Roskill, Auckland .. .. Warkworth . . .. New Lynn, Auckland .. ■. Wellsford Newmarket, Auckland .. .. Wliangarei .. .. Horahora, Whau Valley. Whangarei (Country) South Auckland District. Cambridge .. .. • • Pio Pio ... . . Mahoenui. Gisborne No. 1 .. .. .. Putaruru Gisborne No. 2 .. .. • • Rotorua . . .. Mamaku, Murupara, Te Hamilton East .... .. Wliaiti. Huntly .. .. Pukemiro, Te Kauwhata. Ruatoria .. .. Matainata .. .. Tirau. Taumarunui ... .. Kakahi. Morrinsville .. .. ... Taupo .. .. .. Tokaanu. Ngaruawahia .. .. Glen Massey, Raglan. Te Aroha .. .. Tahuna Ohura .. .. ■ • Te Awamutu Opot.iki .. .. Omarumutu, Taneatua, Te Karaka .. .. Matawai. Torere, Maraenui. Te Kuiti .. .. Waimiha. Otorohanga .. .. • • Tikitiki .. ,.. Te Araroa. Paroa .. ., .. Maketu, Matata, Poroporo, Tolaga Bay .. . . Tokoinaru Bay. Pukehina, Ruatoki, Wairoa .. .. ,. Tawere, Te Teko, Waio- Whitiora (Hamilton) hau. Unattached, .. .. Awakino,

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Centres at which School Dental Clinics were established as at 31st March, 1940-continued.

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Main Treatment Centre. i Authorized Sub-bases. Main Treatment Centre. I Authorized Sub-bases. Wellington District, Carterton .. .. Greytown. New Plymouth No. 1 Dannevirke .. .. .. New Plymouth No. 2 Eketahuna .. .. Tiraumea, Woodville. Ohakune .. .. Raetihi. Eltham .. .. .. Opunake Featherston .. .. Martinborough, Pirinoa. Ormondville .. . . Takapau. Feilding .. .. ., Pahiatua Gonville .. . . .. Patea . . .. . . Waverley. Hastings No. I .. . . .. Stratford .. .. ' Hastings No. 2 .. .. .. Taihape Hawera . . .. .. Waipawa .. .. Otane. Hunterville . . .. Mangaweka. Waipukurau .. .. Porongahau. Inglewood .. . . .. Waitara .. .. Urenui. Manaia .. .. .. Wanganui Central Marton . . .. . . Wanganui East Masterton .. .. .. Wanganui Mobile (Country) Schools from Nukumaru to Masterton (Country) .. .. Turakina. Napier .. .. .. Unattached .. .. Kaponga, Olcato, Pongaroa, Whangamomona. Inner Wellington District. Blenheim .. .. .. Palmerston North (Terrace Eastbourne .. .. .. End) Levin .. .. .. .. Pelorus Sound (Te Puru) .. Manaroa, St. Omer, Te Lower Hutt .. .. .. Towaka, Waikawa Bay. Palmerston North (Central) .. Petone Palmerston North (College .. Shannon Street) Sounds (Picton) .. Havelock, Rai Valley. Palmerston North (King .. Thorndon, Wellington Street) Upper Hutt Unattached .. .. Otaki. Canterbury District. Addington .. .. .. Papanui Ashburton East .. Tinwald. Phillipstown, Christchurch Ashburton West .. .. Rakaia .. .. Methven. Beckenham, Christchurch.. Opawa. Rangiora Brightwater .. .. Richmond, Stoke, Tahuna- Reef'ton .. .. Inangahua Junction, nui, Wakefield. Murchison, Waiuta. Christchurch East .. . . Runanga .. .. Blackball, Taylorville. Darfield .. .. . . St. Albans, Christchurch .. Fairlie .. .. .. Pleasant Point. Shirley, Christchurch Geraldine . . .. .. Somerfield, Christchurch Greymouth .. .. .. Southbridgc .. .. Leeston. Hawarden .. .. Cheviot, Hanmer. Spreydon, Christchurch Hokitika .. .. Harihari, Kokatahi, Sumner Kumara, Ross, Waiho Sydenham, Christchurch Gorge, Wataroa, Woheka. Takaka .. .. Collingwood. Hornby .. .. .. Temuka .. .. Winchester. Kaiapoi . . Waimairi. Timaru Main Kaikoura .. .. Ainseed, Oaro. Timaru West Linwood, Christchurch .. .. Waimataitai, Timaru Linwood Avenue, Christ- .. Waimate church Westport .. .. Denniston, Granity, Hector, Lyttelton .. .. .. ICaramea, Millerton, Motueka . . .. Upper Moutere, Tasman. Seddonville, Stockton, Nelson . . .. . . Waimangaroa. New Brighton .. .. .. Woolston Oxford Otago District. Alexandra .. .. Clyde,Cromwell, Pembroke, Oamaru (Country) .. Kurow. Queenstown. Orepuki Balclutha .. .. Clydevale. Otautau .. . . Nightcaps, Ohai. Dunedin .. .. .. Palmerston .. .. Seacliff. Macandrew Road, Dunedin .. Port Chalmers Forbury, Dunedin .. .. Ranfurly .. .. Middlemarch, Naseby, Gore .. .. . . Mataura. Omakau, Oturehua. Invercargill .. . . .. Riverton Kaitangata .. .. Clinton. Tapanui .. . . Lawrence, Roxburgh. Lumsden . . .. .. Tuatapere Milton .. .. .. .. Winton Mornington .. .. .. Woodlands .. .. Bluff, Stewart Island. Mosgiel .. .. Green Island. Wyndham .. .. Edendale. Oamaru .... I

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APPENDIX A.

THE CONTROL OF DIPHTHERIA IN A RURAL HEALTH DISTRICT. By H. B. Turbott, M.8., D.P.H., Medical Officer of Health, Hamilton. The history of diphtheria in South Auckland Health District has been one of recurring outbreaks alternating with periods of low incidence. The records held locally go back to 1926. In the period 1926-39 there occurred 1,329 cases of diphtheria, with 39 deaths. In spite of modern treatment, the disease has still been dangerous, for about 3 in each 100 children contracting the infection have died. In 1936 an examination of the records for the previous decade showed undue diphtheria incidence 1929-33, followed by low levels in the next three years. It was decided to prevent further waves of incidence, if possible, by commencing an immunization campaign in 1937 while the trough of low incidence still held. During 1937-38 mass immunization of school-children was effected. Altogether 10,034- children were dealt with through the schools, approximately 53 per cent, of the school population being immunized with anatoxin, receiving three doses of | c.c., 1 c.c., I c.c. at intervals of three weeks. As far as the school population was concerned, the result was satisfactory for immunizing purposes. Only 783 pre-school children attended for immunization, a little over 5 per cent of the pre-school age population of the district. It is generally held that for safety in a preventive campaign against diphtheria about 50 per cent, to 70 per cent, of school, and about 30 per cent, of pre-school children need to be immunized. The local campaign was therefore about 20 per cent, low in protection of toddlers and pre-school children. During 1939 the mass campaign being over, immunization was continued as a routine measure in each school medically examined. The School Medical Officer offered immunization at each school inspected, to all new entrants, to any pre-school children offering, and also to any older pupils who missed protection at the big campaign and now desired it. All acceptors are immunized with three doses of anatoxin after a preliminary Moloney test. In practice over the year this meant three weeks of school medical inspection followed by two weeks of immunization, thus keeping the two activities running co-incidently as a routine. A further 998 children were protected during the year, mainly new entrants, with a rising proportion of pre-school children. The results to the present time are most encouraging. The work began to tell in 1938. Several small outbreaks occurred in areas where schools had been done, but, in except one instance, the cases occurred in the group who refused immunization. The exception was a boy of six years who attended for the first dose only. The district diphtheria rate fell to equal the lowest level for the fourteen years recorded here. In 1939 the brunt of diphtheria again fell on the uninoculated. One school, supposed to have been included in the campaign, suffered an outbreak of several cases. A check-up revealed the unexpected and unfortunate fact that, though planned for inclusion, the school had been missed. Surrounding schools protected in the campaign were unaffected. The omission was made good, and after immunization no more cases occurred. Another school urgently requested immunization for an outbreak limited to those refusing inoculation in the mass campaign. Among the inoculated, 3 cases of proven diphtheria occurred. One of these was said to have been immunized against diphtheria in 1936 in Queensland, but as parents get inoculations mixed there is an element of doubt in this case. A second case had reduced doses only, because of susceptibility to anatoxin. The third had the full three injections. A fourth child, who had had two injections, was notified as a case, but proved to be an ear carrier only with no diphtheria clinically. Three cases are therefore returned as diphtheria in the inoculated. In the uninoculated, 32 proven cases occurred, 31 in children, only 4of these being pre-school children. The number of pre-school children in the district being unknown accurately, a differential rate is struck for schoolchildren only. The case rate per 1,000 school-children in the district for 1939 was 0-29 in the inoculated against 1-80 in the uninoculated. The district incidence for the year shows a further fall in the rate per 10,000 population to 2-53, the trend being shown in the following table : — 1936 .. .. 64 cases of diphtheria .. 4-78 per 10,000 of population. 1937 .. . . 88 cases of diphtheria .. 647 per 10,000 of population. 1938 .. .. 57 cases of diphtheria .. 4-19 per 10,000 of population. 1939 .. .. 35 cases of diphtheria .. 2-53 per 10,000 of population. One hopes that the present low rate will continue and even further improve ; while no conclusions are drawn as yet, the above facts are encouraging, justifying continuance of artificial immunity work throughout the district.

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APPENDIX B.

PROGRESS IN PREVENTION OF TYPHOID FEVER IN MAORIS. By H. B. Turbott, M.8., D.P.H., Medical Officer of Health, Hamilton. Preventable intestinal disease takes heavy toll of the Maori. Typhoid and paratyphoid fever caused in 1937 (last available figures at writing-time) thirty-nine times more deaths among Maoris than among Europeans. Bacillary dysentry is in the main unnotified, but many deaths, especially in infants, are due to this disease. Diarrhoea and enteritis caused over seventeen times more deaths in Maoris in 1937 than in pakehas. These diseases have taken toll because of ignorance of the cause and mode of spread, helped by faulty personal and community hygiene in primitive living-conditions. The preventive attack has been concentrated upon typhoid fever, for if headway is made here the battle against dysentery and summer diarrhoea will be won also, similar modes of spread prevailing. The attack on typhoid, if successful, will affect the whole group of preventable intestinal diseases adversely affecting the Maori. Fifteen years ago the attack on typhoid centred round sanitary improvements, but progress was hardly perceptible. In 1928 in East Cape mass inoculations bi-annually of Maori school-children were begun against typhoid fever. After a few years this saved enough children to cause the typhoid rate to fall. As other Maori districts were opened, anti-typhoid inoculation work spread. Yearly anti-typhoid inoculation of Maori school-children has become a routine practice, in addition to the routine inoculation of all contacts of actual cases. This work gradually had effect, for the typhoid death-rate of fifteen years ago was about two and a half times worse than the 1937 bad rate. The provision of safe water-supplies and better sanitation played but little part in this improvement, for sanitation actually deteriorated in Maori areas during at least a decade of the period concerned. By 1938 it was obvious that anti-typhoid inoculations had achieved their quota of success and that these must be continued to maintain that success. It was also obvious that the lagging sanitation must be given attention if further improvement was to be made. In. South Auckland in .1938 a survey revealed 80 per cent, unsatisfactory water-supplies, and 62 per cent, of homes lacking privy accommodation. In the Waikato in 1939 a special sanitation campaign was effected. Four counties were completely covered, all Maori homes broadcasting bodily wastes being supplied with privies. Seven hundred prives were built, transported, and erected, the Maori supplying labour on the site, the Government giving the privy. After broadcasting of faeces has been made obsolete, safe water-supplies will be sought generally. The housing of half the Maori people is still deplorable, but to rehouse the Maori would cost millions of pounds, and is economically impossible. The attack on typhoid is twofold for the present; yearly inoculation campaigns should be reinforced by sanitation drives to eliminate those particular sanitary weaknesses helping the spread of intestinal disease. This was done in the Waikato ; yearly inoculations since 1937 reinforced in "1939 by concentration on soil sanitation. Acceleration in progress is already apparent from a glance at district figures for typhoid and paratyphoid fever in Maoris: — 1936 .. .. .. 39 cases .. .. .. 23-92 per 10,000 Maoris. 1937 .. .. 38 cases .. .. .. 22-62 per 10,000 Maoris. 1938 .. .. .. 29 cases .. .. 17-05 per 10,000 Maoris. 1939 .. .. .. 3 cases .. .. .. 1-71 per 10,000 Maoris. Undoubtedly 1939 was a good year as regards notifiable disease, but even allowing for this and a probable swing-back from this present very satisfactory state, preventive work seems to be telling in the fight against typhoid.

B—H. 31.

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APPENDIX C.

MAORI DIET. By H. B. TtfEBOTT, M.8., D.P.H., Medical Officer of Health, Hamilton. Before the pakeha visited New Zealand Maori diet was eminently satisfactory. Proteins and fats came mainly from fish and shell-fish, from either fresh or sea-water ; from fowl (pigeons, mutton birds, parrots, ducks, kiwi), either fresh or preserved in their own fat in the case of pigeons and mutton birds ; occasionally from human flesh in time of war. After the Hawaiki migration there was added a plentiful supply of rats, and a limited one of dogs. Vegetables gave the chief carbohydrate supply from fern-root, and horse-shoe fern-root, raupo, and cabbage-tree roots, tree-fern pith and certain curly fern-fronds, nikau, tiori, and cabbage-tree inner basal leaf-head, edible seaweed, and mushroom from coast and bush. Fruits and berries were used in season, notably the tawa, hinau, and karaka berries. After Hawaiki, kumara, yam, taro, and gourds became available where the climate allowed their cultivation. These natural foodstuffs, besides giving adequate protein, carbohydrate, and fat were rich in minerals and vitamins, and proved body protective as well as adequate for growth and support. Water was the universal and only drink. Early observers—Captain Cook, Surgeon Savage, Major Cruise, and others have borne testimony of the sound constitution and healthy body of the pre-pakeha Maori. With the advent of the pakeha came western diet. Introductions were made into Maori diet with unfortunate results. Little of the old diet now remains. Fish is seldom caught and shell-fish rarely collected ; it is bought, and figures little on the regular , menu because of price. Flesh foods are restricted for similar economic reasons. Puha is the one relic of the old bush vegetable supply, but this is gathered only once or twice a week nowadays. Kumara persists too, where it can be grown. The balance has been upset, for introductions have been mainly carbohydrate. Potato, white flour, and bakers' bread, sugar, cereals, maize, pork, fresh or tinned meats and fish, and tea are the staple foodstuffs. Milk, used by about half the people, is an acquired taste. Butter is used in minimal amounts, cheese rarely, as it is not liked. Eggs are favoured by about half the people only, and are rarely home produced. Fresh, green vegetables and fruit are insufficient. The diet is high in carbohydrate, short in first-class protein, lacking in vitamins:, and deficient in minerals. Deficiency in vitamin A leads to frequency of common ailments such as colds, septic complications, and infections. It is below the correct level in the Maori diet, so short in fats from fish, animals, milk, and butter. Vitamin D, bound up with fats, is also deficient, lowering resistance to disease. Calcium lack combined with low vitamin D leads to softening and decay of teeth. The lack of adequate greens, of wholemeals, and of fruit means shortage of vitamins B and C. The dislike of milk, eggs, and cheese spoils any hope of making up mineral deficiencies, of calcium, phosphorous, and iron. The Maori diet is no longer well balanced, and the Maori body is not disease-resistant as in pre-pakeha days. For one year over two hundred Maori households were closely watched as regards the daily dietary. Information was sought through questioning and also by observation at meal-times. The questionnaire method elicited the following story: Meat was used daily by 33 per cent., three times weekly by 28 per cent., once or twice weekly by 34 per cent., and less than once weekly by 5 per cent. Fish was eaten once or twice a week in 8 per cent, only ; eggs two or three times weekly by 25 per cent, and only occasionally by 43 per cent. ; milk for tea only in 42 per cent., for tea and cooking or drinking in 39 per cent.; butter was too variable to record, seeming to depend on the state of the family exchequer, and not being mentioned unless leading questions were asked. As regards vegetables, potatoes and kumaras were eaten separately or together according to supply, but one or other formed the daily foundation diet, together with tea, and bread, bakers' bread if it could be afforded, otherwise camp oven unsalted bread without " rising." The tea was drunk sweetened without milk in 58 per cent. Other vegetables were short in the diet. Greens, either puha once or twice weekly, or pakeha cabbage or greens, were claimed as used by 66 per cent, frequently and 22 per cent, only occasionally. Maize-cobs were eaten by 30 per cent., marrow and pumpkin 55 per cent., parsnips and carrots 11 per cent., onions 24 per cent., turnips 4 per cent., seaweed 2 per cent. This questionnaire information was checked by observation from visits without warning at meal-times, a record being kept of what the family was observed to be eating at that meal. As each family was visited from six to a dozen times in the period, a picture of foodstuffs actually consumed at various meal-times is gained, everything seen in use being recorded. From this information the

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following table is constructed, really a record of the daily diet noted in 213 families from repeated observation :—

No variation is made for children, unless infants. At the end of 1939 a family in the course of a visit ate their midday meal. The family of five, two adults and three children under five years, had an apparently satisfying meal of white bread plucked from the big loaf, pieces being soaked in sweetened milkless tea from time to time, and the children happily eating to repletion. That the Maori diet of to-day is ill balanced is proven by giving dietary additions. More and more Maori schools are being given a daily half-pint ration of pasteurized or malted milk. The schoolteachers almost universally report improved nutrition and less scabies, impetigo, and colds. In a carefully controlled Lake Taupo area experiment, the giving of half a pint of milk, with either cod-liver oil or adexolin added, helped suppress the incidence and development of dental caries. Not only is the present diet ill balanced, but it is soft and pappy, providing insufficient jaw exercise and gum massage. From whatever angle the Maori diet be viewed it proves faulty. The pakeha is partly responsible in that he has introduced his foodstuffs without inculcating knowledge of their correct proportional use. While it is difficult to alter dietary habits in adults, young Maoris are susceptible. The best attack on the dietary problem is undoubtedly correct teaching in school years ; some Native .schools are giving this, but fuller exploitation of school and other preventive avenues is needed to cope with a widespread Maori need.

Approximate Cost of Paper.—Preparation, not given ; printing (960 copies including graphs), £80.

By Authority: E. V. Paul, Government Printer, Wellington.—l94o.

Price Is. 3d.J

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Number of Families using J Breakfast. Midday. j Evening Meal. Drinks — Tea .. .. .. .. 194 186 142 Cocoa .. .. .. .. .. .. 1 Water .. .. .. .. . . 1 Flesh foods — Meat .. .. .. .. .. 95 37 170 Fish .. .. .. .. .. 4 6 10 Dairy-produce— Butter .. .. .. .. .. 104 97 55 Milk .. .. .. .. .. 67 42 50 Eggs .. .. .. .. .. 14 2 2 Carbohydrate-high foods— Bread .. .. .. .. .. 181 173 111 Cereals .. .. ..... .. 48 Puddings .. .. .. .. . . 8 19 Sugar .. .. .. .. .. 59 51 53 Jam .. .. .. .. .. 31 30 Honey .. .. .. .. .. 5 Vegetables — Potatoes .. .. .. .. 81 39 167 Kumara .. .. .. .. .. 60 34 142 Greens or puha .. .. .. .. 17 17 98 Pumpkin or marrow .. .. .. 17 .. 27 Maize .. . . .. .. . . 8 3 Onions . . . . .. .. .. 5 Carrots or parsnips . . .. .. .. .. 2 Seaweed .. .. .. .. .. .. .. 4