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Description of the Dispensary Routine.
Primary Examination and Diagnosis of New Cases.
A. Notified cases and others known io have Tuberculosis.—The Tuberculosis Officer examines
every patient carefully in order to ascertain the type and extent of the disease, and in many cases
repeated observations are made in order to determine the most suitable line of treatment.
In some cases it is possible for the Tuberculosis Officer to form a definite opinion immediately
after the first examination or in the course of a few days, but in others a period of observation may
be necessary, particularly in regard to ascertaining the line of treatment most likely to be successful.
This period varies considerably, but it does not generally extend beyond one month.
It should be mentioned that the absence of those aids to diagnosis which are provided by
X-rays considerably diminishes the efficiency of the Dispensary.
B. Suspects.—Suspects are persons in whom there is some reason to believe that active
tuberculosis may be present. They come to the notice of the Dispensary staff in the following
ways:—
(a) "Contacts" * who are not in the best of health.
(b) Cases referred to Dispensary by School Medical Officers, Welfare Medical Officers,
the Medical Officer of Health and general practitioners for examination and expert
opinion.
(c) Cases referred on suspicion by voluntary workers attached to various organisations
interested in Public Health.
(d) Patients attending on their own initiative or recommended by friends.
A person coming under any of these headings is regarded as a "suspect" from the moment he
first attends the Dispensary until a definite diagnosis is made. If clear signs be found it is possible
to make a diagnosis of active tuberculosis almost immediately; but, as a rule, suspects are generally
in a low state of health but do not show any definite signs of disease, and consequently it may
take several months of observation before a final opinion can be formed. Frequently in the case
of children it may be necessary to have other conditions, such as enlarged tonsils and adenoids,
removed before a diagnosis can be made. A very difficult case may require observation over a
period of six months, but, generally speaking, the diagnosis is settled within one to three months.
C. Contacts.—When the Tuberculosis Officer diagnoses pulmonary tuberculosis in a patient
referred to him by a private medical practitioner, he asks the doctor if he would like the contacts
of the case to be examined at the Dispensary. If such examinations be desired, the Tuberculosis
Officer instructs one of the Dispensary nurses to arrange appointments. When patients other
than those sent by medical practitioners are found to be suffering from pulmonary tuberculosis the
Dispensary nurses receive similar instructions forthwith.
On receiving her instructions the nurse visits the home to explain to the contacts, or their
parents, the importance of an early examination by an expert, and she endeavours to induce them
to attend the Dispensary, offering each a definite appointment at a time convenient to both the
contact and the Tuberculosis Officer. Failure to keep the appointment is followed by a second
visit to the home, when a second appointment is offered, and, if necessary, a third visit is paid in
order to offer a third appointment.
On attending the Dispensary the contact is carefully examined and necessary observations
are made, as in the case of suspects, until a definite opinion can be formed as to whether the
person is tubercular or not.
Action taken when a definite opinion has been formed by the Tuberculosis Officer.—Patients
examined on behalf of general practitioners are referred back to their own doctors, the Tuberculosis
Officer sending any necessary report. In some cases a consultation follows, at which the line of
treatment (Dispensary, Residential or Domiciliary) is determined.
War Pensions cases return to their own medical men, and any necessary report is sent to the
War Pensions Committee.
Definite cases of tuberculosis in insured persons are reported to the Insurance Committee,
together with a recommendation as to whether the treatment should be Dispensary, Residential or
Domiciliary.
Contacts, suspects and others not sent by medical men, and found to be tubercular, are
advised to secure appropriate treatment, but if this cannot be obtained satisfactorily they are
treated at the Dispensary. Those found to be non-tubercular are informed accordingly, and any
appropriate advice is given; in many cases the patient is advised to attend again in six or twelve
months' time in order that the Tuberculosis Officer may note that his condition is satisfactory.
Treatment.—During the War there was a large number of attendances at the Dispensary made
by persons who simply visited the institution periodically in order to obtain a bottle of medicine or
a tin of cod-liver oil and malt. The results looked very satisfactory in the annual reports, but it
should be remembered that if the Tuberculosis Officer be largely occupied in "handing out"
cod-liver oil he is prevented from fulfilling his proper functions as an expert.
This view is recognised by the Dispensary Committee, with the result that straightforward
cases not requiring specialised treatment are referred, where possible, to private doctors, and
(* A "contact" is a person living close in association with a notified case of pulmonary tuberculosis.)