Tuberculosis, social inequality, and the hospital in nineteenth-century Scotland

Medical practice surrounding tuberculosis (TB) treatment in two nineteenth-century Scottish charitable hospitals reveals that in developing empirically-positioned constructs of this and related diseases, medical practitioners drew upon social assumptions about women and the working classes, thus reinforcing rather than shedding cultural notions of who becomes ill and why. TB is a social disease, its distribution determined by relationships among human groups; primary among these is the patient-practitioner relationship, owing to the social role of medical treatment in restoring the ill to both health and society. To clarify the influence of cultural context upon the evolution of medical constructs of TB, I examined Glasgow Royal Infirmary (GRI) and Royal Infirmary of Edinburgh (RIE) ward journals, admissions registers, and institution management records from 1794 through 1905. Medical practice at the turn of the nineteenth century was dominated by observation and questioning of the patient, concordant with conceptions of physicians' labor as mental rather than physical. This changed with the introduction of the stethoscope in the 1820s, which together with the dissection of the poor allowed by the 1832 Anatomy Act ushered in disease concepts emphasizing pathological anatomy. Relationships between patient and practitioner also altered at this time, exhibiting distrust and medical dominance. The mid-Victorian era was notable for clinicians' increasing interest in immorality's contributions to ill health, absent in earlier practice and linked to conceptions of women and the working classes as inherently pathological. In 1882, discovery of the tubercle bacillus challenged existing nutritional, hereditary, and environmental explanations for TB. Although practitioners utilized bacteriological methods, this discovery did not revolutionize diagnosis or treatment. Rather, these older models were incorporated with perceived behavioral, environmental, and biological degradation of the working classes, rendering marginalized groups "soil" prepared for the "seeds" of disease -- at risk, but also to blame. This framework, in which marginalized groups contribute to their increased risk for disease through refusal to accord with hegemonically-established "healthy" behavior, persists. As a result, meaningful change in TB rates will need to address these longstanding contributions of social inequality to Western medical treatment.