(the case of London, if the patient is sent by the London County Council to a residential institution fer a period of observation in order to establish the diagnosis, the Tuberculosis Officer should send Form A to the Medical Officer of the London County Council, who will transfer it to the Medical Officer of the institution. When the diagnosis has been completed the Medical Officer of the London County Council will inform the Tuberculosis Officer of the result of the observation and of the subsequent action to be taken in the case.) In those cases in which, at first, the diagnosis is doubtful, and in which ultimately it is decided that the person is not suffering from tuberculosis, no other Form need be filled in, but the completed Form A should be filed for future reference (but separately from the case records which deal with definite cases of tuberculosis only). The names of persons in whom there is no evidence of tuberculosis on first examination (e.g., " contacts" who have neither signs nor symptoms) should be entered in the dispensary register; but no records are needed in respect of such persons, although the Tuberculosis Officer may consider it advisable, for his own information, to keep notes of the physical examinations in these cases. The result of every examination of sputum (or other material) should be recorded on Form A or Form C (i). In order to establish the diagnosis and classification, a thorough search for tubercle bacilli is essential in all cases (including "obvious" cases) of pulmonary or suspected pulmonary tuberculosis in which the patient has any expectoration. If there is a negative result, the sputum should be re-examined several times before it can be considered to be free from tubercle bacilli. During the course of treatment, specimens need only be examined in those cases where the presence or absence of bacilli will be an important factor in deciding upon the future line of treatment or the desirability of discharge from treatment. Thus the presence or absence of tubercle bacilli in the sputum will often determine the future course of treatment of a patient having physical signs compatible with an arrested lesion, but with occasional traces of sputum. In such a case a single negative result will not warrant a conclusion that the sputum is free from bacilli. In other cases, the desirability of treating advanced cases in hospital will be materially influenced by the abundance or paucity of bacilli in the sputum. While it is impossible to lay down any rule as to the frequency with which examination of sputum should be made, the foregoing considerations may be usefully borne in mind. In the classification of cases the system detailed in Section 4 of this Memorandum should be followed. It is recognised that no completely satisfactory method of classification of pulmonary tuberculosis has yet been devised, and no attempt is here made to elaborate a final and exhaustive classification for clinicians. The object is rather to indicate those patients in whom permanent benefit is most likely to result from Sanatorium treatment (Group 1); and, on the other hand, to separate from the main bulk of cases those for whom residential treatment would naturally, in the first instance, take the form of treatment in a hospital for advanced cases (Group 3). It will be open to Tuberculosis Officers and Medical Officers of residential institutions to adopt any reasonable method of further subdivision if this is desired. The Tuberculosis Officer should enter the classification on the Form as soon as possible. It will be observed that pulmonary cases in whose sputum tubercle bacilli have actually been found are clearly separated from those in whom the bacilli have never been found. This does not of course imply that the latter class should not receive treatment; on the contrary, it is important that such cases should receive adequate treatment. It has not, however, been considered necessary for the purpose of the prescribed annual returns to subdivide this class into groups. Form B. 10. The Tuberculosis Officer should be responsible for securing a report upon Form B in the case of every patient. Form B is divided into two parts: (1) a report upon the environmental conditions of the patient; and (2) a record of the examination of the home" contacts" of the patient. As regards (1), it is essential in administrative counties that there should be full co-operation with the Medical Officer of Health of the sanitary district concerned, in order that visits to the homes of patients and the information thus obtained may be co-ordinated, overlapping of effort avoided, and sanitary defects remedied. As regards (2), it is desirable that the examination of the home" contacts" of the patient should be made by a Tuberculosis Officer, who should fill in a Form A for any "contact" whom he discovers or suspects to be suffering from tuberculosis, and thus open a case record for such a contact.' Form B should be brought up to date from time to time, and any action taken with a view to improving home conditions should be recorded so long as the patient remains at home, whether under domiciliary treatment or dispensary treatment or supervision. In the event of the patient changing his residence it will of course be necessary to fill in 2 fresh Form B. Forms C (i), C (ii), and G.P. 36. 11. Form C (i) is suggested for the purpose of reports on progress, which should be made by the Tuberculosis Officer: (1) Periodically at intervals of not more than three months in all cases of patients undergoing dispensary treatment, and at least once in twelve months if the patient is under "general supervision "* only or is also receiving domiciliary treatment; and (2) Whenever the patient is transferred from the dispensary to the care of another medical attendant, or from dispensary treatment to general supervision only, or is discharged from public medical treatment. Form C (ii) should be filled in by Medical Officers of residential institutions and sent to the Tuberculosis Officer-in the case of patients from London, through the London County Council (1) Periodically at intervals of not more than three months, and (2) On the patient's discharge. The Local Authority should furnish a supply of the Form to any institution not under their own control to which they may send patients. Form G.P. 36 is the form prescribed under the National Health Insurance Medical Benefit Regulations for use by Insurance Practitioners in reporting upon insured persons who are receiving domiciliary treatment upon the recommendation of a Tuberculosis Officer. The Tuberculosis Officer should attach all such reports to the case record. Reports on Forms C (i), C (ii) and G.P. 36 will contain sufficient information to enable the line of treatment previously adopted to be followed, if thought desirable, by the medical practitioners successively taking charge of the case. Additional Records. 12. It is considered that the information for which the model Forms provide constitutes the minimum "case record" which should be kept of every patient suffering from tuberculosis who comes under public medical treatment, but it is recognised that Tuberculosis Officers and Medical Officers of residential institutions may desire to keep other detailed records, such as temperature charts and other clinical notes required for the regulation of treatment, and records bearing on special investigations in regard to tuberculosis. Such additional records need not form part of the transferable case record. Registers. 13. In order to secure that the statistical information to be supplied to the Chief (Administrative) Tuberculosis Officer will be readily available, it is desirable that every Tuberculosis Officer and the Medical Officer of every approved residential institution should keep a register. The dispensary register should contain information as to all persons dealt with at or in connection with the dispensary, including, in addition to patients suffering from tuberculosis, persons coming for advice, observation cases and contacts. The register of a residential institution should contain information as to " patients" and observation cases. A book register combined with a card or loose leaf index will probably be found most convenient. General Procedure. 14. From the time a patient† first comes under public medical treatment until his discharge or decease he should be considered as continuously under the "general supervision" of the Tuberculosis Officer. It is important that, so far as practicable, each patient on the dispensary register should be kept under general supervision for a prolonged period both in his own interest and in the interest of "contacts" whom he may infect. A patient may at different times be in receipt of different forms of active treatment (residential, dispensary, or domiciliary), but such treatment should be considered as in addition to and not in substitution for " general supervision." All patients on the dispensary register should, as far as practicable, be seen and examined at least once a year by the Tuberculosis Officer, and their homes should be visited periodically by the Health Visitor or dispensary nurse, acting under the directions of the Tuberculosis Officer.. See Section 14 below. + See definition in Section 15. patient definitely diagnosed as suffering from tuberculosis should not be discharged as cured: until arrest of the disease has been maintained for three years; see Section 5. In the case of "contacts" found on examination not to be suffering from tuberculosis and whose names have therefore been written off the Dispensary Register, arrangements should be made to secure, as far as possible, that such cases are brought again to the notice of the Tuberculosis Officer, if suspicious symptoms arise, particularly cases of "contacts" of patients suffering from pulmonary tuberculosis and classified as T.B. plus. Treatment at the dispensary, as distinct from diagnosis, consultation, and general supervision only, should as a rule be limited to those patients whose continued treatment requires special knowledge or technical skill, or who are unable to obtain other adequate medical attendance. Patients whose treatment does not call for the exercise of experience or skill beyond that which general practitioners ordinarily possess, and who are either insured persons or who can afford to pay for medical attendance, should not be encouraged to attend the dispensary for routine treatment. On the other hand, a patient who is considered by the Tuberculosis Officer to require general supervision only and no regular systematic treatment should not be referred to his general practitioner for treatment. In such a case the Tuberculosis Officer should fill in Form C (i) once a year. Definitions of Terms. 15. Throughout this Memorandum the following terms have these meanings:---(a) "Local Authority": The Council of a County or County Borough in England (excluding Monmouthshire), or a Joint Committee of such Councils, constituted under Section 64 (3) of the National Insurance Act, 1911, for the exercise of all the powers of the constituent Councils in regard to the institutional treatment of tuberculosis; the Corporation of the City of London; the Council of a Metropolitan Borough. (b) "Chief (Administrative) Tuberculosis Officer": The Medical Officer of Health of the Local Authority (or other Medical Officer appointed with the approval of the Minister of Health to supervise the administration of the Local Authority's tuberculosis scheme). (c) "Dispensary Area": An area (whether whole or part of a Local Authority's area) which is under the clinical charge of one Tuberculosis Officer, with or without assistants. (d) Public Medical Treatment": Treatment at a dispensary or residential institution or "general supervision," under a scheme approved by the Minister of Health for the treatment of tuberculosis, of a person who has been diagnosed to be suffering from tuberculosis. (Note.--A patient under domiciliary treatment should be regarded as also under "general supervision" by the Tuberculosis Officer). (e) Patient": A person who has been diagnosed to be suffering from tuberculosis and is under public medical treatment for tuberculosis. (The term does not include a person who is kept under observation pending the establishment of the diagnosis, and who is referred to in the Memorandum as an "observation case," but includes all persons on the dispensary register who are under "general supervision," even if not in receipt of any treatment). (f)"Dispensary Treatment": Treatment by a Tuberculosis Officer in cases where the patient is seen not less frequently than once in every month, and is examined not less often than once in three months. (9) "Domiciliary Treatment": Treatment of an insured patient by his Insurance practitioner on the recommendation of the Tuberculosis Officer. (4) “ Year": The calendar year ending on the 31st day of December. MINISTRY OF HEALTH, September, 1925. (Schedule 1.) Borough,} County, County Borough, or Metropolitan Borough TABLE 1. Council of........... Annual Return showing the work of the Dispensary (or Dispensaries) during the year (*)......... NOTES. Tuberculosis Officer. (N.B.-Notes 1 to 5 below repeat definitions (d) to (h) on p. 7 of Memorandum 37/T.) (1) Public Medical Treatment.-Treatment at a dispensary or residential institution or "general supervision," under a scheme approved by the Minister of Health for the treatment of tuberculosis, of a person who has been diagnosed to be suffering from tuberculosis. (Note.-A patient under domiciliary treatment should be regarded as also under "general supervision" by the Tuberculosis Officer). (2) Patient.-A person who has been diagnosed to be suffering from tuberculosis and is under public medical treatment for tuberculosis. (The term does not include a person who is kept under observation pending the establishment of the diagnosis, and who is referred to in the Memorandum as an "observation case," but includes ali persons on the Dispensary Register who are under "general supervision," even if not in receipt of any treatment) (3) Dispensary Treatment. Treatment by a Tuberculosis Officer in cases where the patient is seen not less frequently than once in every month, and is examined not less often than once in three months. (4) Domiciliary Treatment.--Treatment of an insured patient by his Insurance practitioner on the recommendation of the Tuberculosis Officer. (5) Year. The calendar year ending on the 31st day of December. (6) Adults. For the purposes of Tuberculosis Records all patients of 15 years and upwards should be classed as adults. (7) New Cases.— (a) All persons examined for the first time at, or in connection with, the Dispensary, except definite cases of tuberculosis transferred from the areas of other local authorities. Persons seen in consultation, who will subsequently be dealt with by their own private practitioners, should be included. (b) Persons who have been dealt with previously by the Dispensary and discharged as "cured," or provisionally diagnosed as not, at that time, suffering from tuberculosis, who return to the Dispensary as suspected cases of tuberculosis. (8) Observation Cases.-Persons attending at, or in connection with, the Dispensary, in whose cases the Tuberculosis Officer cannot, within a period of one month from his first examination of the case, come to a definite diagnosis after physical examination and the application of the necessary tests. In completing sections A and B, such cases should be entered under sub-head (b) in each section. (9) Dispensary Register.-List containing names of all persons attending at; or seen in connection with, the Dispensary for diagnosis or for treatment for tuberculosis, including patients under "general supervision (whether or not accompanied by domiciliary treatment), and patients or observation cases in residential institutions, and "contacts." (This must be distinguished from the Notification Register kept by the Medical Officer of Health.) cured (10) Cured.-Patients with tuberculosis should not be deleted from the Dispensary Register as until in the case of non-pulmonary tuberculosis, 3 years, and in the case of pulmonary tuberculosis, 5 years, have elapsed without any symptoms of active disease (i.e., arrest has been maintained for 3 years). (11) Cases "lost sight of."-Patients who have failed to submit themselves for examination during two consecutive calendar years notwithstanding all efforts to trace them. These should be written off the Dispensary Register at the end of the year. (Patients who are known to have left the district permanently but who cannot be transferred to another local authority because their destination is not known, and patients seen only in consultation for the purpose of diagnosis, and others who desire no further assistance under the tuberculosis scheme for public medical treatment, may be marked off at once.) County or County Borough Council of TABLE II.-RESIDENTIAL INSTITUTIONS. (A) AVERAGE NUMBER OF BEDS AVAILABLE FOR PATIENTS (B) ANNUAL RETURN SHOWING THE EXTENT OF RESIDENTIAL TREATMENT |