Clubbed fingers, long eyelashes, and a subaverage condition: unusual markers of tuberculosis in the Royal Victoria Dispensary case notes

This week, Rebecca takes a look at the Royal Victoria Dispensary case notes, exploring the wealth of information collected from each patient before they were clinically examined.

Diagram of the Edinburgh Scheme, showing the central role of the dispensary.
(LHSA Slide Collection)

 

I’m currently working on a series of case notes from the Royal Victoria Dispensary, the outpatient clinic which acted as the first point of contact for people suspected of having tuberculosis in Edinburgh. The dispensary, based on Spittal Street with an additional clinic in Leith, saw thousands of people each year.

The former dispensary on Spittal Street, Edinburgh
(screenshot from Google Street View ©2014 Google)

Being referred to the dispensary was not a sign that someone had tuberculosis, rather it was a way for likely cases to be examined and a diagnosis of tuberculosis eliminated. Patients would be referred for a number of reasons: they may have lived with or been related to a notified case of tuberculosis; their GP or School Medical Officer may have referred them based on their symptoms; they may have been sent for a ‘large film’, a more detailed X-ray to check on any abnormalities detected during mass radiography; or they might require examination before entering certain professions. For example, all apprentices in the printing trade would be screened, as it was an industry with a high mortality rate from tuberculosis, attributed to crowded working conditions. Others requested to go in for an ‘overhaul’, usually due to nervousness that they had the condition.

When they arrived, the patient would be quizzed on a variety of factors which would give a general background to their health and lifestyle. But what exactly was it that was being looked for?

Case note, for a symptomless contact of TB, showing the standard checks performed at the RVD
(LHB41 CC/2/PR2.5695)

Firstly, a patient would be questioned on the presence of key symptoms including coughs and sputum, dyspnoea (breathlessness), and haemoptysis (coughing up blood). Temperature, pulse, and weight gain or loss would also be recorded - not for nothing was TB also known as ‘consumption’, as dramatic weight loss would often accompany the condition. Other symptoms such as night sweats or the presence of finger clubbing, associated with severe pulmonary tuberculosis, would also be recorded.

Pulmonary tuberculosis can often be present without visible symptoms, so factors such as the size of the patients’ family and any family history of tuberculosis were also recorded. Tuberculosis spreads following prolonged close proximity to sufferers, so a close relationship with a sufferer was worth investigating. The patient’s occupation would also be noted, in order to ascertain if they worked in a dusty occupation or a physically taxing position. This information was also a valuable indicator of poverty and poor living conditions, which were associated with tuberculosis and which a doctor would have borne in mind when recommending treatments.

Case note from 1949, includes a record of the smoking habits of the patient -
note that this is not pre-printed on the form.
(LHB41 CC/2/PR2.5704)

From the 1940s onwards, case notes also note how many cigarettes a patient smoked per day, which is interesting considering the relationship between smoking and lung cancer was first proposed, and not immediately accepted, around 1950. Smokers who were found to have some lung symptoms were usually told to stop or curtail their smoking, which goes against the impression that many people now have of the popular and clinical attitudes towards tobacco consumption at the time.

A final note on the patient’s general condition (‘subaverage’, ‘satisfactory’, etc.) would also be made. A few case notes refer to ‘long eyelashes’, referring to an earlier idea of two forms of tuberculous patient; the beautiful, delicate consumptive, with long eyelashes and fair complexion, and the other with “coarse, thick features” and a sallow complexion. If a patient was perceived to live in poor conditions, to be malnourished, or to have an unsatisfactory personality, this would often be recorded as well.

Note on a patient's general condition: "GC Fair only. but not bad for age"
(LHB41 CC/2/PR2.5717)

All of this information would be recorded before a patient even got so far as a clinical examination or an X-ray, and it is not clear from the case notes if this part of the examination was carried out by a doctor or not. But it was important for all of this to be recorded, and it is obvious from the case notes that this information was a useful aide in determining if a patient was suffering from pulmonary tuberculosis. As well as this, these case notes also provide a fascinating insight into the work and habits of tens of thousands of Edinburgh residents in the post-war period.

Sources:

LHB41 CC/2/PR2

Cairns, Margaret; Stewart, Alice, ‘Pulmonary Tuberculosis Mortality in the Printing and Shoe-making Trades. Historical Survey, 1881-1931.’, Brit. J. Preventive & Social Med., 5 (2), (Apr 1951), pp. 73-82 http://www.cabdirect.org/abstracts/19512703370.html;jsessionid=53F6E61EACAA51F66F6650F988C4EE89?freeview=true

Imray, Keith, A popular cyclopedia of modern domestic medicine : comprising every recent improvement in medical knowledge : with a plain account of the medicines in common use, (1849), available at: https://archive.org/stream/63580420R.nlm.nih.gov/63580420R
Macfarlane JT, Ibrahim M, Tor-Agbidye S., ‘The importance of finger clubbing in pulmonary tuberculosis.’, Tubercle, 60 (1), (Mar 1979), pp. 45-48.

Ruddock, E. H., The diseases of infants and children and their homœopathic and general treatment, (1899), available at  https://archive.org/details/b28134825

Woodcock, H de Carle, ‘Adolescent and other forms of tubercle’, Tubercle¸5, 2, Nov 1923, pp.64-69 http://www.sciencedirect.com/science/article/pii/S0041387923800939

‘Smoking and cancer of the lung: minister’s press release and statement in House of Commons’, Tubercle, 35, 3, (Mar 1954), pp.70-72) http://www.sciencedirect.com/science/article/pii/S004138795480047X

An example of obsolete treatment in the Norman Dott Case Notes (1920-1960): lobotomy.

     The Norman Dott case notes are an invaluable source for the history of neurosurgery. They contain many examples of pioneering medical techniques, but also of treatments and diagnoses which are now obsolete. One of the most striking examples is the psychosurgical procedure on the frontal lobe better known under the name ‘lobotomy’. Nowadays, this word evokes a botched, barbaric practice that trampled the rights of patients and stripped them of their individual and humane qualities. However in the 40s and 50s, this operation was regarded as a way to relieve some patients of their sufferings when all the other treatments had failed.

     In Britain, where the term ‘leucotomy’ was used rather than the American word ‘lobotomy’, the first operations were carried out at the Burden Neurological Institute in Bristol in 1940, at the instigation of Frederick Golla, Effie Hutton and F. Wilfred Willway. The use of the procedure peaked in the late 1940s and early 1950s, with nearly 1500 operations a year. However, the poor results of the operation, the harmful consequences observed in patients, and the progressive introduction of psychiatric drugs led to a sharp decline of the practice by the end of the 1950s. The vast majority of the case notes I have been working on as the cataloguing archivist of the Norman Dott project date from this period; and indeed, out of the 2500 case notes I have catalogued so far, less than twenty mention a leucotomy. However, these cases greatly help to understand in what context it was used and on what kind of patient, and for which results.

     The vast majority of patients who underwent a leucotomy in the Norman Dott case notes at the end of the 1950s were women, aged from 24 to 73 years old. They were usually suffering from various mental illnesses described in the case notes as: ‘hebephrenic schizophrenia’, ‘catatonic schizophrenia’, ‘chronic depression’, ‘agitated depression’; or more precisely: ‘long-standing and deep seated neurotic illness in an inadequate personality’, ‘recurrent depression with maniac depressive personality’.

     Doctors were well aware that leucotomies were not a ‘miracle solution’, far from it. They knew that recovery was not guaranteed and that it could change the patient’s personality and make them less socially apt; however the alternative was judged worse and the goal was to dull the symptoms of psychiatric illness to enable the patient to lead a more peaceful life or at least to make him or her easier to nurse. This sentiment is expressed by two doctors considering a leucotomy at the Royal Infirmary for their patients: ‘I think that leucotomy would relieve his suffering and might make it possible for him to make some sort of adjustment outside hospital’; ‘[I feel] that a leucotomy would allow of a modified social recovery enabling [the patient] to lead a fairly normal life though leaving her rather ineffectual and needing guidance in her day to day activities’.

 

Excerpt from a case note relating to a female patient suffering from chronic depression, 1959. LHB1 CC24 PR2.20898.

     One must keep in mind that the procedure was only used as a last resort. The patient had to be in a deeply disturbed state which would make living in these conditions unbearable. Again quoting from Norman Dott case notes, it is said that one patient ‘was inaccessible and auditorily hallucinated. There was considerable volitional retardation and she was monosyllabic’. For another patient, ‘operation was especially commended because of intractable noisy perseveration; the word “money” occurring endlessly’. Moreover, leucotomies were only performed when all other treatments had failed: in the case note PR2.20920, it is said that ‘ECT has only produced temporary improvement and tranquillizers have not been effective’, in the case note PR2.20698, the doctors who examined the patient agreed that ‘he should have a leucotomy carried out in view of the prolonged period of unsuccessful conservative treatment’. At the time, other treatments included electroconvulsive therapy (ECT), tranquilizers, and modified insulin injections, also known as insulin coma therapy (ICT).

The following extract from a case note describes a leucotomy performed in 1959 on a patient suffering from ‘agitated depression’ at Ward 20 of the Royal Infirmary of Edinburgh. Essentially, the surgeon would drill a pair of burr holes into the skull in order to insert a sharp instrument called a leucotome into the brain, that he would then sweep from side to side to separate the frontal lobes from the rest of the brain.

Operation notes describing a leucotomy, 1959. LHB1 CC24 PR2.20920

     From what we can gather, the outcomes of the leucotomies carried out in the Norman Dott case notes were very mixed. Only one patient seemed to do better: ‘in the few days after the operation and prior to her return to Bangour, [the patient] certainly appeared more relaxed, approachable and less disinclined to talk’. However most of the time the results were more disappointing: ‘little change was noted after operation’; ‘however, [in the following days], there was some suggestion of her being less accessible’; ‘in the first post-operative days [the patient] was confused and towards the end of the first week still disorientated in time; somnolent and incontinent of urine and faeces. He recognised his surroundings; knew that he had been operated on and why. There was no appreciable change in his mood’ and he ‘still appear[ed] to be grossly preoccupied and depressed’. Unfortunately, the case notes only mention the days immediately following the operation so we have no way of knowing how the situation evolved for these patients on the long term, but from other leucotomy cases, we know that it was not uncommon for patients to be crippled for life or to live in a vegetative state.

     The use of leucotomy has been criticized from the very beginning for the risks it posed for the patients and for its very limited and often unpredictable results, although it was performed in situations in which the doctors thought that the benefits would outweigh the risks. The cases we find in the Norman Dott collection, although few in number, enable us to understand the context of this operation, and what the reasoning behind its use was. The study of medical failures and outdated treatments is essential to understand the evolution of neurosurgery.

Sources:

History of psychosurgery in the United Kingdom [online]. Wikipedia. Available from: https://en.wikipedia.org/wiki/History_of_psychosurgery_in_the_United_Kingdom [Accessed 19/05/2016].

Levinson, H. (2011), The strange and curious history of lobotomy [online]. BBC News magazine. Available from: http://www.bbc.co.uk/news/magazine-15629160 [Accessed 19/05/2016].

Happy 200th Birthday to the stethoscope!

When you picture a doctor in your mind, what do they look like? Are they wearing a long white coat? Carrying a clipboard? Chances are, draped around their neck is a stethoscope. An iconic object, the stethoscope turns 200 this year. To celebrate, Alice is looking back at the history of the stethoscope in Edinburgh… 

The stethoscope was invented in 1816 by the wonderfully-named Rene Theophile Hyacinthe Laënnec (phew!). The practice of listening to the sounds of the body as a method of diagnosis is known as auscultation, but before the stethoscope came on the scene, most diagnosis was done through observation and interviews with patients, and any attempts at auscultation required the doctor to place his ear directly onto the patient. In a world before deodorants and dental hygiene, many doctors felt that this physical contact was improper and unseemly – not to mention a bit smelly. Some even felt that a ‘good’ doctor shouldn't need to touch a patient – he should be able to diagnose by observations alone. Patients weren't too keen on physical contact either - women in particular felt that the process was invasive and degrading.

Laennec's stethoscope, c 1820.
By Science Museum London / Science and Society Picture Library -  CC BY-SA 2.0, 

Dr Laënnec's solution was simple but very, very effective. He had found himself struggling to diagnose a patient because her weight prevented him from being able to hear her heart, and immediate auscultation – the ear-to-skin approach – was out of the question because of her sex. Laënnec improvised, possibly inspired by his other life as a flautist. He rolled up a piece of paper “into a kind of cylinder and applied one end of it to the region of the heart and the other to [his] ear, and was not a little surprised… to find that [he] could thereby perceive the action of the heart in a manner much more clear”. 

While the idea of stethoscopy was well received in Britain, it took a while for the stethoscope to become the ubiquitous tool of the physicians' diagnostic arsenal that it is today. While many were keen on the instrument in theory, they didn't know how to use it in practice. The scientific art of auscultation involves a lot more than simply listening: it requires an educated ear to correctly interpret what is heard. In 1822 Dr Andrew Duncan, one of Edinburgh's early enthusiasts, tried to employ the methods he had read about, but found that "it requires attention and some adroitness to apply [the stethoscope] properly at one end to the chest of the patient, and at the other to the ear of the observer", and in the end conceded that he "had not acquired skill enough" to use it effectively.  

Dr William Cullen seems to have reached the same conclusion. In the same year as Duncan was experimenting, Cullen submitted a thesis to the Royal College of Surgeons of Edinburgh which detailed the "usefulness of the stethoscope...in a manner which suggests he had had some experience of the use of the instrument” (Nicholson, 1993:144). In order to improve his skills, Cullen travelled to Paris to study under the masterful Laënnec himself, and by 1824 Cullen was back in Edinburgh and holding his own classes on stethoscopy.

With an educated teacher to instruct them, the Edinburgh medical community embraced the stethoscope: it became a feature of their medical textbooks from 1828, and in the same year Dr N. P. Comins (a physician at the Royal Infirmary of Edinburgh) remarked proudly that the new, more flexible stethoscope that he had designed was now being used in every one of the Infirmary's thoracic cases.

A stethoscope from LHSA's Objects collection

The stethoscope had well and truly arrived, and now this humble instrument is 200 years old. In light of ever-improving non-invasive diagnostic techniques, some medical commentators have questioned whether it still has a place in modern practice, but a study published earlier this year by the European Society of Cardiology argued that “the time-honoured stethoscope, in spite of its limitations, still has potential as a patient-friendly, effective, and economical instrument in medical practice”. Whatever the future for this iconic instrument, we are pleased to celebrate 200 years of stethoscopy. Thank you, Rene Laënnec!

If you'd like to see a stethoscope like Laënnec's up close, the National Museum of Scotland will have one on display in their new Enquire Galleries later this year, so 'keep an ear out'...!

______

Sources

Nicolson, M. (1993). The introduction of percussion and stethoscopy to early nineteenth-century Edinburgh. In: W. Bynum and R. Porter, ed., Medicine and the Five Senses, Cambridge: Cambridge University Ppess, pp.134-153.

Conservation and cake!

Earlier this week Ruth attended what is now an annual get together for Scottish conservators to share ideas and news. Employing a pecha kucha approach, 18 speakers had five minutes each to talk to a room packed full of conservators representing the major nationals for library, museum, art and archive collections, as well as universities, councils and those in private practice. There were also a few aspiring conservators, with students and volunteers there too.


The Centre for Research Collections hosted the event, following in the footsteps of 2015’s host, the National Library of Scotland (NLS), and it was great to be able to welcome so many professionals with shared goals and backgrounds to talk about recent developments in our field. I spoke at last year’s event, presenting a whistle-stop tour of our internship programme for archivists and conservators, but this year I confined myself to loading up all the PowerPoints, enjoying the presentations, and tweeting using #PaperConservators.

All the presentations were well-rehearsed and interesting, but stand-out ones for me touched on some of the issues that we deal with when working to preserve the LHSA collections. Isobel Griffin from NLS talked about prioritising collections for treatment, and being clear and transparent when describing the processes conservators use and the decision-making that lies behind those objects that aren't treated as well as those that are. Mary Garner spoke about preparing collections for mass digitisation, and while we're not doing that with LHSA collections, it is an area that we need to keep up-to-date on to inform our smaller scale digitisation work. Gloria Conti from the National Records of Scotland presented a case study which captured perfectly the relationship a conservator can establish with those represented in the records we preserve - and the responsibility we have to treat the data in the records and, by extension the individuals themselves, sensitively.

A question and answer session with some of speakers

There were also a couple of papers on treating wallpaper in situ: Helen Creasy looked to the historic pinned and tacked repairs on the wallpaper she was tasked with conserving and used toned stainless steel staples to reattach flaking pieces of the paper that couldn't be held in place with conventional adhesive methods. Again, wallpaper is not something we have to deal with here, but Helen inspired me to think creatively when addressing damage to collection items to find the best solution for each case (though I don't think I'll be replicating any of the historic repairs I see on the LHSA collections - Elastoplast doesn't meet any of a conservator’s basic requirements for an appropriate and ethical repair!).


(As a little side note, it was a great to see Ryan Gibson’s presentation showcasing some recent films made by the conservation department at NLS - he very kindly credited our handling video as inspiration for their efforts! https://www.youtube.com/watch?v=56SE_5J-E50&feature=youtu.be.)

Conservation and cake don't often mix but, as there were no collection items around, some delicious home-baking kept us going through the afternoon - it turns out some of the clever conservators that attended the event are brilliant bakers too!