Friday, 1 July 2016

"...still not wearing stockings!": advice and recommendations from the Royal Victoria Dispensary

This week, Rebecca continues her exploration of the case notes from the Royal Victoria Dispensary, examining what they teach us about the treatment of tuberculosis throughout a period of drastic changes.

Last time I wrote here I described the signs and symptoms that the doctors of the Royal Victoria Dispensary (RVD) were looking for when a patient attended for examination. This time, I will look at what happened next.

A typical case note from the RVD (LHB41/CC/2/PR2.5741)
Following the initial examination, patients would be x-rayed and clinically examined. A diagnosis could then be made, based on which recommendations would be given. The majority of patients who attended the dispensary did not receive a diagnosis, though sometimes they displayed signs which meant that the doctor would recommend them to rest up for a while. Of the patients who received a diagnosis, many had respiratory issues such as bronchitis, asthma, or some form of ‘catarrh’, and only a small proportion of patients would be diagnosed with tuberculosis. Cardiac diagnoses would also be given on occasion, chiefly mitral valve stenosis or mitral incompetence. 

Examples of recommendations given to patients who attended the dispensary.

(Clockwise from top L: "To stop smoking and to keep earlier hours - crooning in a dancehall: attending every night except Sundays", "To keep earlier hours", "To stop smoking To be less in the company of the 'boy friend'", "To wear stockings", "To stop smoking + excessive tea-drinking", "To stop smoking To stop dancing at nights". )
If tuberculosis was diagnosed, recommendations were given for the treatment of the patient. Most of these were fairly standard, such as taking bed rest, being put on waiting list for a hospital, or being sent to their GP for treatment. Patients might also be advised to seek better employment, generally because their work was too dusty or strenuous to be compatible with effective recovery. 
Sometimes the recommendations were a little more, for want of a better word, patriarchal. Patients (particularly young women) would be told to stop going out dancing in the evenings, or to wear stockings – sensible advice, but very different to what we would expect from our GPs nowadays. Women could be refused permission to marry, or at least told not to get pregnant - married women could be referred to family planning services, and therapeutic abortions were occasionally considered for the sickest patients.

Extract of a case note from a patient eager to get married, who is "told that the matter will not be considered until the first year after discharge." She is eventually "allowed to get married with explanation of reservations."

Extract of a case note from a recently married patient, who is referred to the Mothers' Welfare Clinic and fitted with a 'Dutch cap'.
The dispensary was not able to provide much by way of treatment for tuberculosis. Instead, patients with severe tuberculosis would be referred to one of Edinburgh’s hospitals, generally City Hospital or the Royal Victoria Hospital, where they could receive supervised bed rest and surgical treatment.
For patients with a less severe diagnosis, not much could be done – they would be told to rest and referred to the almoner to apply for a Tuberculosis Allowance so that they didn't have to work and they would return for regular monitoring to check to progression of the disease, but there were no medications available to be given until the 1950s when the more serious cases were increasingly given some combination of anti-tuberculosis antibiotics, usually PAS with Streptomycin.

A bay full of RVD case notes in our store room - each box contains around 500 case notes!

By our current estimate, we have over 20,000 case notes from Royal Victoria Dispensary from the 1940s and 1950s. The individual case notes are not very thick, but the sheer volume of them means that they provide a great insight into the running of the dispensary. This was the period in which antibiotics and mass radiography led to a massive and permanent decline in the rate of tuberculosis, and these records really show us the transformations that were taking place in how patients would be referred for examination, what signs were being looked for, and the changes in treatments and care given over this short period. The records of the RVD therefore allow us to gain a real insight into what was happening at this pivotal moment in the treatment of tuberculosis in Edinburgh.


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