One of the most interesting aspects of being an archivist is
developing one’s knowledge on a new subject by diving into the primary source
material. Cataloguing the case notes from the Royal Victoria Dispensary has
enabled me to learn a lot about tuberculosis, its symptoms, the diagnosis techniques,
and the treatment methods in the 50s, and I’d like to share this knowledge
today.
Tuberculosis and its different sites
Tuberculosis (TB) is a disease caused by bacteria
(Mycobacterium tuberculosis) that most often affect the lungs. It is spread
from person to person through the air and is very contagious, that’s why many
people were sent to the Royal Victoria Dispensary because a family member, a
friend or a neighbour had been notified. The most common symptoms described in
the case notes are: a cough with or without sputum, dyspnoea (difficulty to
breath), haemoptysis (coughing up blood), ‘lassitude’ (fatigue), chest pain, and weight loss.
Perhaps a less well-known fact is that TB can also affect
other parts of the body, in this case we talk of extra-pulmonary tuberculosis. The
case notes from the Royal Victoria Dispensary focus on detecting and treating
pulmonary tuberculosis, but I have come across different kinds of tuberculosis:
meningeal TB, a form of bacterial
meningitis caused by the bacteria mycobacterium tuberculosis and which leads to
headaches, seizures, cranial neuropathies, somnolence and coma; military TB, an acute form of
tuberculosis in which the minute tubercles are formed in a number of organs of
the body due to dissemination of the bacilli through the blood stream; osteoarticular TB, or tuberculosis of the
joints and bones, including the spine – learn more in this blog post –; urogenital TB, which affects the
urogenital system and may cause a persistent cystitis, dysuria, and ulcer; gastrointestinal TB,
which involves any region of the gastrointestinal tract and causes abdominal
pain and fever; and finally lymph nodes
TB, which infects the lymph nodes[1].
Diagnosis methods
The people sent to the dispensary would come for different
reasons: many of them had been in contact with a person known to have
contracted tuberculosis, some of them were sent by their doctors because they
presented some symptoms, and some were there to get a ‘check-up’ before immigrating
to another country. However, tuberculosis can be latent, or its symptoms can be
caused by many other diseases, so it is not easy to diagnose it straightaway. By
the late 50s, several tests were used to determine if a patient had
tuberculosis. One of the most straightforward ways to identify a disease of the
chest was X-ray, and this technique was systematically used on the patients who
came to the dispensary. If a person had had TB bacteria which had caused inflammation
in the lungs, an abnormal shadow was visible on the chest X-ray.
 |
Excerpt from the case note LHB41 CC2 PR2.13695 showing the
interpretation of an X-ray. The patient suffered from pulmonary tuberculosis
and died less than a year later. The text says: ‘Extensive fibrocaseous disease
both upper lung zones, more marked on L[eft] than right with system of cavities
in 1st, 2nd ant[erior] interspaces. Large cavity at inner
end of 1st right ant[erior] interspace.’
|
Another test very often carried out was the ‘sputum test’,
that is to say the examination of the sputum under microscope to detect the
bacteria responsible for tuberculosis. Up to the 1950s, bacteriologic diagnosis
was mainly by bright field examination of direct smears stained by the
Ziehl-Neelsen method.
When
a patient wasn’t able to produce sputum by coughing, a ‘gastric lavage’ was
performed so that doctors could check the gastric contents for the bacteria that cause
tuberculosis.
However,
these techniques were only useful to detect pulmonary tuberculosis, and because
the vast majority of people who have TB germs in their bodies do not have an
active case of the disease[2]
and thus show no symptoms, skin tests were also used to detect if someone had been infected with TB germs. They were
done on people in contact with someone known to have had TB; people with TB
symptoms, or people who presented an abnormal chest X-ray. The case notes I have been
cataloguing show examples of two of these techniques: the Mantoux test and the Heaf
test. Both tests consist in injecting tuberculin purified protein
derivative (PPD) into the forearm, with a syringe in the Mantoux test, and with
a Heaf gun (a spring-loaded instrument with six needles arranged in a circular
formation) in the Heaf test. The reaction was read several days later by
measuring the diameter of induration across the forearm in millimetres:
depending on the test and on the patient’s medical risk factors, an induration of over 5mm,
10mm, or 15mm would be considered positive, and would mean the person had been
infected with TB. The Mantoux test is still widely used around the world, and the
Heaf test was used in the UK up to 2005 to determine if the BCG vaccine was
needed. Patients who exhibited a negative reaction to the test were considered
for BCG vaccination, which was also offered at the Royal Victoria Dispensary,
as you can read here.
Treatment
Once it was determined that a patient
was suffering from active tuberculosis, treatment was started. Before the
introduction of antibiotics in the 40s and 50s, doctors recommended bed rest in
large, well-lit airy buildings. When the sick person started to feel better,
gradual exercise was introduced. Patients were sometimes sent to Switzerland to
breathe some fresh air, although this was a costly option, and therefore they
were more often sent to local sanatoriums. The Southfield Sanatorium case
notes, also a part of the RVD v TB project, are a great way to look into the
functioning and daily life of these establishments [click here to learn more].
 |
| Open air treatment at Southfield Sanatorium Colony, Liberton, Edinburgh. |
More ‘aggressive’ procedures were
also performed, such as the artificial pneumothorax, a surgical treatment to
collapse the lung by inserting air or nitrogen into the pleural space. This
served two purposes: first to allow cavities created in the lungs to close and
heal, and second to decrease the amount of extracellular bacteria expelled by
an infected person’s coughing and breathing. Even though no such procedures
were performed at the Royal Victoria Dispensary, I have come across cases of
patients who came to the dispensary for supervision after having undergone
them.
The discovery of antibiotics led to a rapid decline in the mortality
of tuberculosis. The case notes I have been cataloguing date from the late
fifties, when antibiotics were widely used. I have come across mainly three:
PAS, or para-aminosalicylic acid, streptomycin, and isoniazid. Streptomycin was isolated in 1943 and was the first antibiotic found to be effective against
tuberculosis, whereas isoniazid was first made in 1952. Both these antibiotics are still
part of the five first-line drugs in treating tuberculosis today. PAS was
introduced to clinical use in 1944, and is more expensive and less potent than
streptomycin and isoniazid, although it’s still useful nowadays in the
treatment of multi-drug resistant tuberculosis.
Nowadays in the UK, tuberculosis is not perceived as a
serious threat by the general public anymore. It is seen as a disease of the
past, associated with poverty and terrible living conditions. However, while it
is true that the progress of medicine has drastically reduced the number of
tuberculosis cases, the disease has far from disappeared: HIV/AIDS patients are
particularly vulnerable to it, and the emergence of multi-drugs
resistant strains means it will become more and more difficult to cure.
Sources:
Lothian Health Services Archive, LHB41 CC/2/PR2
Medical Subject Headings thesaurus of the US National Library of Medicine, available from: https://www.nlm.nih.gov/mesh/MBrowser.html [Accessed 07/10/2016]
Mitchison D., 'The Diagnosis and Therapy of Tuberculosis
During the Past 100 Years', American
Journal of Respiratory and Critical Care Medicine, Vol. 171, No. 7 (2005),
pp. 699-706.
Niemi R. (4
November 2014), Tuberculosis Treatments
Past and Present [online]. Intellectual ventures Lab. Available from: http://www.intellectualventureslab.com/invent/tuberculosis-treatments-past-and-present
[Accessed 06/10/2016].
[1] Interestingly, this disease is also called
the King’s Evil because French and English kings were said to have the power to
cure it just by touching it.
[2] According to the Centre for Disease Control and Prevention, 'without treatment, about 5 to 10% of infected persons will develop TB disease at some time in their lives'. http://www.cdc.gov/tb/publications/factsheets/general/ltbiandactivetb.htm
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