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importance of the early diagnosis of doubtful cases. The Council's tuberculosis
scheme of 1914 stipulated that dispensary schemes must include provision, either in
the dispensary or at a hospital working in connection with the dispensary for the
diagnosis not only of ordinary cases but also of incipient, anomalous and difficult
cases, and that the dispensary should be linked up with a hospital to which special
cases should be referred for consultation or treatment, residential or otherwise.
In practice few cases of doubtful diagnosis were referred by tuberculosis officers
to the consulting centres at hospitals, and as regards diagnosis at the dispensaries
it was found that generally speaking there was a lack of intensive study of doubtful
cases, which were often kept in attendance for observation for long periods. The
congestion arising from the accumulation of these observation cases, resulted in these
cases ceasing to be observed, and there was no time for physical examination of
even a tithe of them. Tuberculosis officers frequently gave medicine for trifling
symptoms or in some cases even for no medical reason in order to ensure the further
attendance of patients. The arrangements for treatment at the dispensaries also
revealed serious defects. Patients were provided with medicine whether needed or
not, with the result that the drug bills were unnecessarily heavy, and patients were
encouraged to rely more on medicine and less on advice on such essential matters
as personal and home hygiene and diet. Another matter in which there was an
obvious need for improvement was the question of co-operation between the
dispensary and other agencies. Sufficient use was not made by the dispensary of
the information available through the periodical examination in the elementary
schools of children on the dispensary registers, and there was room for more effective
co-operation with general practitioners. One of the most conspicuous defects in
the dispensary organisation was the lack of attention paid to what is termed " aftercare,"
in which is included such questions as the suitable employment of tuberculous
patients.
Closely connected with all these matters was the question of the adequacy of
the dispensary staff. It was found that there was a considerable variation in the
amount of time devoted by tuberculosis officers to their duties. Allowing for the
fact that defective organisation was responsible for a certain amount of wasted
time, it was apparent that if the dispensary work was to be put on a satisfactory
basis it would be necessary to increase the number of assistant tuberculosis officers
and tuberculosis health visitors, and to relieve the tuberculosis officers of the clerical
work.
Since 1919 there has been a steady improvement in the organisation and working
of the dispensaries. Co-operation between the dispensaries and the public health
departments has been secmed by the appointment of the tuberculosis officers by
the borough councils as assistants to the medical officers of health. Considerable
attention has been given to the failure to notify cases of tuberculosis, and though
there has been some improvement, there is still an unduly high proportion of cases
that remain unnotified, many of them even until the patient's death. Statistics
furnished by a number of boroughs show the following average percentage of the
number of cases dying unnotified or dying within three months of notification.
1920.
49 per cent.
1921.
53 per cent.
1923.
44 per cent.
1924.
44 per cent.
Greater attention has been given in the dispensary to the question of early
diagnosis and the consequent reduction in the number of cases remaining undiagnosed
for long periods has enabled the tuberculosis officers to give more time to
their legitimate functions. It has also resulted in a marked reduction in the use of
drugs.
Arrangements have been made at the dispensaries for evening sessions to be
held for employed patients and special sessions are held for school children. To a