Friday, 27 May 2016

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.

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;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:
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 homÅ“opathic and general treatment, (1899), available at

Woodcock, H de Carle, ‘Adolescent and other forms of tubercle’, Tubercle¸5, 2, Nov 1923, pp.64-69
‘Smoking and cancer of the lung: minister’s press release and statement in House of Commons’, Tubercle, 35, 3, (Mar 1954), pp.70-72)

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