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.
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.
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 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.
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.
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].
 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.
 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