The tuberculosis officer in order to be able to treat his dispensary patients with adequate knowledge, and in order to advise as to the form of treatment—in a residential institution or not,—most fitted to the patient’s case, must know the sanitary and social circumstances of the patient’s industrial and domiciliary life. He must, therefore, have reports on these circumstances respecting each patient. This raises the general question of the relation of the tuberculosis officer to the medical officer of health. The medical officer of health is officially responsible for controlling the tuberculous patient and his environment from a public health standpoint. As the tuberculosis officer also needs the information acquired in the inquiries which it is the duty of the medical officer of health to make personally or by an authorized agent, coördination of the work of the two officers is evidently required; and this need cause no difficulty when the tuberculosis officer is an officer in the Public Health Department of which the medical officer of health is the chief administrator.
The Home Visitation of Patients
This is important, (a) to inquire into the social circumstances of each patient; (b) to instruct him in detail as to the carrying out of instructions for treatment and in the hygiene of his life; (c) to make a sanitary survey of the dwelling house, and especially of the patient’s bedroom, and to advise as to any needed reforms; and (d) in certain cases to give actual assistance in nursing the patient.
The report on these inquiries should be seen by both the medical officer of health and the tuberculosis officer, and on them in conjunction with the tuberculosis officer’s knowledge of the medical condition of the patient, the subsequent course of supervision and treatment will depend.
Home visitation can be carried out by nurses attached to the dispensary or by inspectors of the public health department. The latter will usually be more competent in detecting and remedying sanitary defects in the home; the former in encouraging the patient to carry out the needed requirements in personal hygiene and nursing. Many visitors are equally competent in both directions; and as the number of women specially trained in tuberculosis work increases this will more generally be the rule.
The dispensary should be the active working centre from which home visitation is undertaken; and this is especially important in “following up” work. Following up is needed for persons who have been examined once, concerning whom there is doubt as to their freedom from disease and who fail to present themselves for later examination. It is needed also for patients who have been under treatment and neglect to continue it; and for patients who after having been treated have been discharged and fail to report themselves at intervals as directed. It is important to have efficient arrangements for ascertaining these leakages and for making the necessary inquiries. The method of securing this will vary according to local circumstances; but the following example given by Dr. Chapman of an official method may be placed on record:
When a patient is instructed to attend again at the dispensary his name is noted in a diary under the date upon which he is asked to attend. In some instances a definite time is fixed for the appointment so as to save the patient’s time. The names of all patients who attended the dispensary upon the day appointed are ticked off as they are seen, and at the end of the day the names of patients who have failed to attend remain on the list. Letters are then sent reminding these patients of their engagement and making another appointment. If they still fail to attend they are visited by the dispensary nurse or the health visitor. Failure to attend may be due to relapse, and, when this is likely, an early visit of inquiry by the nurse is advantageous.
Examination of a register kept for facilitating work of this kind showed that the majority of the patients followed up attended subsequently, and that in the cases of the remainder non-attendance as a rule was satisfactorily explained.
In areas having, as yet, no adequate system of following up, an appreciable percentage of patients usually cease to attend during the course of treatment at a dispensary, and many are lost sight of after discharge from a sanatorium. The value of the work of a dispensary and of after-care work is materially impaired in the absence of a system of “following up.” As schemes develop, more stress will doubtless be generally laid upon this branch of the dispensary function.