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and voluntary—appear to take advantage of the facilities offered by the dispensaries for the examination
of patients. Generally speaking the following list is fairly representative of the various sources from
which patients are derived:—
(1) The London County Council (mainly the School Medical Department).
(2) The London Insurance Committee (mainly panel practitioners).
(3) Borough Council officials.
(4) Boards of Guardians.
(5) War Pensions Committees.
(6) General practitioners.
(7) Hospitals (especially when the dispensary is part of the hospital organisation).
(8) Charitable societies (e.g., C.O.S. and I.C.A.A.).
(9) Contacts of previous definite cases.
(10) Recommended by patients in attendance at dispensary.
(11) Patients coming on their own initiative.
No useful figures as to the use made of dispensaries by War Pensions Committees are available
but it is certainly very considerable. The figures which are available relate to 1918, and are much lower
than those for 1919 will be. Camberwell dealt with about 400. War Pensions cases during the first nine
months of 1919.
Home consultations.—These are relatively few in every area for two reasons—(1) many of the
patients are ambulant cases and the practitioner sends them to the dispensary for an opinion; (2) the
practitioners rarely able to afford time to meet the tuberculosis officer at the beds'de. In many cases
the tuberculosis officer at the request of the practitioner examines the patient at home and subsequently
discusses the case over the telephone with, or sends a written opinion to him. (These cases are not
recorded in Form R as consultations.) Now that the pressure of war conditions is relaxing and permanent
tuberculosis officers are back at work, there is evidence that home consultations are steadily increasing.
The tuberculosis officer of St. Thomas' Hospital is not allowed by the rules of the hospital
to consult at the homes of patients. This is an unfortunate restriction and it is desirable in the interests
of efficiency that the rule should be revised.
There is evidence that co-operation with local practitioners has increased very greatly during
recent years. In 1913 many tuberculosis officers did not make a regular practice of sending a report of
any patient whom they might examine to his doctor. It is satisfactory to record that great attention
is now paid by all the tuberculosis officers to this duty. The majority of tuberculosis officers take every
opportunity of becoming acquainted with and studying the interests of local practitioners, with the
result that co.operation has very materially improved. In some areas, however, there is still room for
considerable improvement in this respect.
Methods of observation.—In the various dispensaries visited it was observed that the fullest use
was not made of all the facilities available for arriving at a definite .diagnosis in doubtful cases. Particularly
one noted that there was a lack of intensive study, more especially, perhaps, in the case of children.
In many dispensaries the tuberculosis officers do not care to discharge patients with definite ill.health
but doubtful in diagnosis; they keep them attending the dispensary for observation and give them
»uch treatment as appears to be indicated. These patients attend about once a fortnight for very long
periods—e.g., a year, and as more and more are constantly added to their number this results in an excessive
number attending at each session ; there is no time for physical examination of even a tithe of those
requiring examination; the observation cases cease to be observed, and the only thing that is done for
many of them is that their medicine is repeated. This condition of affairs is seen to the greatest extent
in the Stepney dispensaries. The number of attendances made by all persons per annum at each of these
dispensaries is very high, and is accounted for mainly by the large number of children in whom no diagnosis
has been arrived at, but who receive treatment. The congestion of these dispensaries is so great
that the tuberculosis officers have no opportunity to give real observation.
In some dispensaries, on the contrary, and this was specially marked in some of the hospital dispensaries,
great pains were taken to arrive at a diagnosis as quickly as possible and each case was studied intensively
for a short period. It is important that stress should be laid in all dispensaries upon the importance
of arriving at a diagnosis without delay. Anything which renders this impossible seriously impairs the
efficiency of the dispensary. When a patient has been submitted to such an intensive study for a period
of (say) three to four weeks, both by the tuberculosis officer and after reference to a consulting centre,
and a positive diagnosis is not even then possible, it is justifiable to request him to attend the dispensary
again in two or three months, and if no further evidence is available of the positive existence of tuber.
losis, he may reasonably be discharged as "probably rot suffering from clinical tuberculosis." The
patient should then be advised to report again in six months or, of course earlier, if any symptoms
develop suggesting the desirability of a further examination.
Consulting centres.—During the year 1918 only one hundred and forty-five cases were referred
to the consulting centres by tuberculosis officers. In nearly every instance these were cases of tuberculosis
which involved some special region or organ—e.g., throat, genito-urinary tract, etc., or in which
some special experience or apparatus was required for the purpose of diagnosis or treatment. It was
surprising to find that so few cases of doubtful diagnosis were sent to the consulting centres. The cases
so referred are few even where the relationship between the physician or surgeon and the tuberculosis
officer is very close. Exceptionally, however, as in the case of a hospital dispensary—at Victoria Park
Hospital—numerous informal consultations (two or three a week) take place with the visiting staff. Careful
inquiry was made amongst tuberculosis officers for the purpose of seeking an explanation of an attitude