Archive for November 2014

Matron’s Medical Report Book – Part 1

The Matron’s Medical Report Book is the earliest surviving record we have from Stannington Sanatorium, which contains monthly updates on patient progress and general administration.  The first entry from the Report Book, below, dates from 1908 and lists some of the earliest patients with details of their ages, addresses and condition whilst in the Sanatorium.    

 

April 11th 1908

“There are now six patients here.  Five have been here for nearly four weeks (since March 18th) & one for three weeks.  They are:-

1. Maggie Smith, aged 17.  Address 73 Leopold St (sent from the Gateshead Workhouse)

2. John Edward Kenney, aged 15 ¾; Address 72 William St, Hebburn Quay (working at Hebburn Colliery)

3. James Robson, aged 13. Address 16 Bottle Bank, South Shields

4. Thomas Hill, aged 12 ½. Address 76 Belvedere St, Heaton

5. John Nicholson, aged 10.  Address 10 Hyiamais Court, Gateshead

6. Thomas Burns, aged 16 ¾. Admitted March 21st. Address 40 Stanley St, Jarrow

 

The general condition of all the patients has considerably improved.  They have all gained in weight during the last 18 days: Maggie Smith 5 ¼ lb, John Kennedy 4lb, James Robson 2 ¾ lb, T. Hill 3lb, J. Nicholson 3 ¾ lb, T. Burns 3 ¼ lb (all given to the nearest ¼ lb).  Only one patient, Maggie Smith, has any marked degree of fever.  There is a slight improvement in her temperature.  One patient, J. Hill, does not cough at all.  All the others are coughing less and bringing up less sputum.

Examination of the sputum for tubercle bacilli has not yet been possible.

The local condition in three patients, T. Burns, T. Hill & J. Nicholson is quite satisfactory, shewing improvement. In two patients, Maggie Smith & J. Robson it has remained about the same.

In one, J. Kennedy, there has been some extension of the diseased area, but improvement again during the last four days after strict rest.”

[HOSP/STAN/2/1/1]

 

The close association of tuberculosis with poor living conditions is further highlighted here by the first two patients who have come from Gateshead Workhouse and Hebburn Colliery respectively.  At this stage there were only 6 patients but the sanatorium had opened not long before this with provision for 40 children and soon saw the beds fill up.  In the following years the sanatorium’s capacity began to expand rapidly with an extension providing an additional 50 beds opening in 1911 and several new wards opening in the 1920s so that by 1926 there were 312 beds available.

HOSP-STAN-9-1-1 aerial view

Aerial view of the sanatorium c.1936

[HOSP/STAN/9/1/1]

We will post some more entries from the Matron’s Report Book in future blog posts to track the progress of the early days of the Sanatorium.

Patient Files

As part of the Stannington collection we have patient case files spanning the years 1939-1966 containing a wealth of medical and social information to support that found in the radiographs.  The earlier files have a different format to the later ones owing to a change in the administration of patient records at Stannington which occurred in 1946.  Up to 1946 the patient records take a much larger format and the patients were all allocated their own unique patient number based on their date of discharge, whereas from 1946 onwards standard sized paper files come into use with patient numbers being based on date of admission.

[HOSP/STAN/7/1/1/1587]

The above file is an example of one of the later files with the patient’s name redacted for confidentiality purposes.  Three different colour files were used, each one indicating the type of tuberculosis the patient was suffering from.  Blue files were used for sufferers of pulmonary TB, pink files for non-pulmonary TB, and finally green files for TB of the bones and joints.  This image gives a good indication of the sort of information that can be found on the files, which is also indicative of the information we will be recording in our catalogue.  The information featured in the catalogue for each patient will be as follows: patient number, date of admission, date of discharge, sex, age on admission, home town, diagnosis, result of treatment, where admitted from, the local authority sending them, and where applicable any re-admission numbers and dates.

 

To clarify some of the information given on the file, the date of immunisation refers to immunisation against diphtheria, not tuberculosis, as widespread vaccination against TB was not yet in place.  As a contagious disease and a major concern for public health, all diagnosed cases of tuberculosis had to be made known to the local public health authorities, which is what the notification date refers to.

 

Each case of tuberculosis had to be classified according to centrally issued guidelines and this is often noted on the patient’s file under diagnosis. The first distinction made when classifying the disease is between pulmonary and non-pulmonary tuberculosis, with pulmonary including TB of the pleura and intrathoracic glands and any patient suffering from a combination of pulmonary and non-pulmonary TB would be classified as pulmonary.  Cases of pulmonary TB could then be subdivided between TB minus and TB plus.  Cases in which tubercle bacilli have never been found in the sputum or other pathology samples are classed as TB minus, as the above patient is.  TB plus on the other hand applies to cases in which tubercle bacilli have at some point been found and is subdivided further into 3 groups; group 1 applying to cases with slight constitutional disturbances if any and limited physical signs, group 3 for cases showing profound constitutional disturbance or deterioration and with little or no prospect of recovery, and finally group 2 for all cases which cannot be placed within groups 1 or 3.  Patients suffering from non-pulmonary tuberculosis would be classified according to the site of the lesion, for example, tuberculosis of the bones and joints, abdominal tuberculosis, tuberculosis of other organs, and tuberculosis of the peripheral glands.

 

There is also a space on each patient file to enter the result of treatment and there were also central guidelines covering this.  Most patients leaving Stannington are deemed to be ‘quiescent’, meaning that they have no signs or symptoms of tuberculous disease and any sputum is free of tubercle bacilli.  A patient’s condition could also be classed as ‘arrested’ by which it is meant that in pulmonary cases the disease has been quiescent for at least two years and in non-pulmonary cases it is quiescent and there is no reason to believe it will recur.  And finally, a patient could be considered to be ‘recovered’ if the disease had been arrested for at least three years.

 

The information that you can expect to find within the patient records does vary from patient to patient but generally includes data on other family members, living conditions, medical history, temperature charts, x-ray reports, pathology reports, details of progress, and any correspondence with family members or local authorities.  The correspondence contained within the files can give a fascinating insight into social problems and the impact tuberculosis could have on families at the time adding an extra dimension to the medical information that we expect to find.  The image below is an example of the x-ray reports that can be found in the back of some of the files; it is quite common for files dating from the mid-1940s to find small diagrams of what was seen in the x-rays also.

 

x-ray reports

[HOSP/STAN/7/1/1/1587]

 

Case Study – Pulmonary Tuberculosis

In this post we’re going to explore the progression of pulmonary tuberculosis in one particular patient from Stannington Sanatorium in order to gain an insight into some of the common approaches to the treatment of the disease at this time.

 

Patient 95/1947 was admitted to Stannington Sanatorium on 4th September 1947 at the age of 12. After having begun to feel ill earlier in the year she was examined at the local clinic and sent for x-ray whereupon it was determined that she should be admitted to the sanatorium for treatment.  Prior to admission she had been living with her mother, step-father, two younger brothers and one younger sister in a 3 roomed house in Cockermouth which had no inside water or inside toilet.  The only family history of TB had been her father who had died from the disease when she was still a baby.  On admission she had no cough but a very poor appetite and was losing weight, weighing only 4st 0lbs 6oz.  There were no other physical symptoms or abnormalities reported.

 

The report on her first x-ray taken 4 days after admission reads:

Tuberculous infiltration of both upper lobes with a large cavity in the mid-zone & a smaller one at the left apex.  There are several small calcified foci in the right upper lobe.”

Continuing reports over the next 4 months describe great improvement on the right side with the cavity in the right mid-zone no longer being visible.  However, the condition of the left side continues to deteriorate with a report 7 months after admission stating that the “cavity in the left upper lobe is now very much larger 1 ½” in diameter.”

 

NRO-3000-HOSP-STAN-07-01-02-1444-19

[HOSP/STAN/7/1/2/1444/19 – tomograph showing large cavity in left upper lobe, Dec 1948]

 

During her stay a series of different treatments were attempted to reduce the cavities.  Two months after admission in November 1947 her doctor initially observed that it was “doubtful if a satisfactory collapse could be obtained.  No treatment recommended.  Outlook very poor.”  Nevertheless, two months later in January an artificial pneumothorax was attempted but without success.

 

Artificial pneumothoraxes were performed on patients with the intention of resting the affected lung and hopefully collapsing the cavities at the same time whilst preventing any further spread as a collapsed lung was less likely to spread bacilli.  The procedure had been shown to effect a marked improvement in the size of tuberculous cavities for some patients but could at the same time be a dangerous procedure with a risk of air embolisms, pleural shock, sepsis, emphysema and effusion.

 

HOSP_STAN_9_1_1

 [HOSP/STAN/9/1/1, artificial pneumothorax treatment being performed in Stannington]

 

Three months later, after observing the growth of the cavity in the left upper lobe, a phrenic crush followed by a pneumoperitoneum was recommended and she was transferred to Shotley Bridge Hospital soon after for the procedures to be performed.  By crushing the left phrenic nerve, situated in the neck, they would be able to disable the left diaphragm thus forcing the muscle to relax and lift up, with the idea being that this would then rest the lower part of the lung.   A pneumoperitoneum was often performed in conjunction with the phrenic crush and involved inserting air into the abdominal peritoneal cavity forcing the diaphragm up.

 

Unfortunately after the patient was transferred to Shotley Bridge Hospital for the above procedures she never returned to Stannington and so we do not have any later case notes to follow up the result of her treatment.  However, some later correspondence does tell us that she was moved to Poole Sanatorium from where she was eventually discharged in May 1950.

 

The surgical procedures described here sound very drastic from a modern perspective but were a common approach in the pre-antibiotic era.  With no effective drug treatments surgical approaches such as these were at the forefront of tuberculosis treatment and looking through the files of Stannington Sanatorium it is clear that many of their young patients recovered, or at least showed significant improvements, and went on to live normal lives.

Types of Tuberculosis at Stannington Sanatorium

Tuberculosis is a bacterium based infectious disease, known as Mycobacterium-tuberculosis. It is a widely held misconception that tuberculosis (TB) is a disease that only affects the lungs. In fact TB can affect any part of the body, both the skeleton and the soft tissue. The key aim here is to identify the various types of TB that affect children and how these affect different parts of the body, with a view to making the patient records and radiographs of the Stannington Sanatorium more understandable.

Primary Infection

Tuberculosis is generally contracted through the inhalation of infected droplets, usually the result of a cough or sneeze, from an individual with active infection. Once inhaled the infection enters the lungs where it manifests itself as a primary complex (Primary TB). Initial infection can be identified by a fever and night sweats which would last up to two weeks, not dissimilar to the effects of pneumonia. This may be followed by skin dullness, weight loss, an increased respiratory rate and haemoptysis (coughing up blood or blood stained sputum). The primary infection goes into a state of incubation during which it multiplies on a small scale to reduce the immune system’s ability to identify its presence, it then spreads throughout the body.

Secondary Infection

There are two ways in which tuberculosis can be disseminated throughout the body, through the lymphatic system and through haematogenous spread (blood stream). The process of widespread dissemination of infection is categorised as miliary tuberculosis, which occurs early in primary infection. It is identified as a series of tiny spots in radiographs, but also causes Chorodial tubercles or pale lesions on the optic nerve which serve as an important symptom in diagnosing this form of TB, particularly in children. Due to its disseminated nature within the body, miliary TB is responsible for a number of other forms of secondary tuberculosis. Organs including the liver, spleen, kidneys, bladder and genitalia are all affected by tuberculosis which are connected to haematogenous miliary TB.

Miliary tuberculosis is also closely linked with the most fatal form of TB, tuberculosis-meningitis. Affecting the central nervous, TB-meningitis has been attributed with a large proportion of tuberculosis related deaths amongst children. It is caused when tuberculosis bacteria infiltrate the fluids surrounding the brain and spinal cord causing small abscesses, which when burst cause tuberculosis-meningitis. It is often identified from symptoms such as irritability, listlessness, headaches and vomiting.

Tuberculosis also manifests itself within the skeletal system. Tuberculosis of the bones and joints is more prevalent in children, and is well represented in the patients of the Stannington Sanatorium. Spinal involvement in tuberculosis, also known as Pott ’s disease, is considered to account for the highest number of skeletal tuberculosis cases. Tuberculosis affects the spine through the destruction of the discs between individual vertebrae and ultimately the collapse of the spinal column causing an identifiable curvature of the spine. The compression or angular result of spinal tuberculosis can proceed to cause paraplegia and/or neurological damage depending on the number and location of the vertebrae involved.

Extra-spinal tuberculosis can be divided into two categories, although they commonly fall under the title ‘bone and joint TB’, the first being tuberculosis-osteomyelitis. The effect of this form of TB is usually characterised by destruction of portions of the long bones and the epiphyses (ends of the long bones), followed by periostitis, the process of new bone growth. In the hands and feet, there is also usually noticeable swelling of the soft tissue in addition to bony anomalies.

The second form of skeletal tuberculosis is tuberculosis-arthritis, which affects the joints, including the hip, knee and elbow. This can be caused by direct invasion from adjoining bones with tuberculosis-osteomyelitis or through miliary TB. Tuberculosis of the joint causes erosion of the joint surface and depletion in the space between the joint. This can subsequently cause septic arthritis of the joint, in which the joint surface is destroyed ultimately causing ankylosis (stiffness and immobility).

Abdominal-tuberculosis is another common extra-pulmonary form of tuberculosis. This was considered a primary form of tuberculosis prior to milk pasteurisation, as individuals could contract the bovine strain of mycobacterium-tuberculosis (mycobacterium-bovis) through the ingestion of contaminated meat or unpasteurised milk. It is characterised by ulcers and thickening of the bowel wall and can lead to the secondary tuberculosis: peritoneal-tuberculosis. Abdominal tuberculosis often healed spontaneously sometimes with calcifications in the abdominal region which act as radiographic evidence of the disease.

Tuberculosis of the pleural cavity, the space found between two layers of pleura surrounding the lung itself, is considered to be a direct complication of primary infection of the lungs. Pleurisy with effusion and empyema are the two most common forms of tuberculosis found within the pleural cavity. Despite the involvement of primary infection within the lungs and the pleural cavity, tuberculosis of the pleural space is considered as an extra-pulmonary form of tuberculosis.

A less common form of TB is tuberculosis of the skin, identifiable by the nodular skin lesions found on the face; the most common form of this is lupus vulgaris.

Finally chronic pulmonary tuberculosis, also known as tertiary, re-infected or adult tuberculosis, where infected bacteria encounter an area already sensitised to the infection. This can occur in children who have had already had primary tuberculosis and usually appears in adolescence and early adulthood.

Stannington Sanatorium

The diagnoses of patients from Stannington Sanatorium display a range of different types of tuberculosis. Pulmonary case files are the most numerous, however these also consist of those patients admitted for non-TB pulmonary conditions such as bronchiectasis. Still once all non-TB patients are removed from the case files, pulmonary or primary TB accounts for a significant proportion of patients treated at the Stannington Sanatorium.

All patients were subject to a chest radiograph upon admission as a diagnostic tool. As a result the radiographic collection holds a predominance of chest radiographs displaying a range of chest related forms of tuberculosis and non-tuberculosis conditions.

Miliary tuberculosis features prominently within the patient files, and is usually associated with those suffering from a severe form of the disease. As an extension of this form of tuberculosis there are also a range of organ, nerve, skin and skeletal related tuberculosis cases.

Stannington also offers a generous proportion of bone and joint tuberculosis allowing for detailed examination of the ways different bones were affected by the infection. This allows for the study of skeletal progression of the disease, particularly useful for comparative purposes when looking at tuberculosis in archaeological collections.

 

Sources

Meningitis Research Foundation: http://www.meningitis.org/disease-info/types-causes/tb-meningitis

Harisinghani, M.G; McLoud, T.C; Shepard, J.O; Ko, J.P; Shroff, M.M; Mueller, P.R (2000). Tuberculosis from Head to Toe, in Radiographics pp.449-70. http://www.ncbi.nlm.nih.gov/pubmed/10715343

Sir Henry Wellcome

The Stannington Sanatorium Project has been generously funded by the Wellcome Trust, a M0007847 Photograph of Henry Wellcome (three-quarter face with beard)charitable foundation designed to aid research into, amongst others, Medical Humanities to explore the social and historical aspects of scientific and medical practices.

 

 

Henry Wellcome, influenced by his uncle, a town physician in Garden City, Minnesota, USA, took an interest in drug and pharmaceutical research from a young age. On leaving school at 13 years old, he took up a position in the local drug store, where his role was to mix compounds for his uncle and where he later began to experiment with his own compounds. Taking his interests in drug development further, Wellcome went on to study firstly in Chicago and then at Philadelphia specialising in marketing and drug production.  On graduating college he took up a job as a pharmaceutical travelling salesman for Caswell Hazard & Co. It was during this time that his research into the cure of tropical diseases began after being sent to Peru and Ecuador to study raw materials that may lead to new drug developments.

 

In 1880 Wellcome entered into a partnership with a former classmate, Sillas Burroughs, to form the company Burroughs, Wellcome and Company in London. Using a technique previously developed by the drug firm John Wyeth and Brother, Burroughs, Wellcome and Company introduced the compressed pill, or tablet, to the British and European markets, offering a much safer, standardised dose than medicines prepared by pestle and mortar.

The business flourished and by 1883 they had addressed stamp duty costs for American imports by manufacturing their own compressed pills in Britain. Production was initially slow, so a team of engineers were commissioned to design a more efficient machine giving them a marked edge over competitors in quality and production levels. The competition was further eliminated by the introduction of the trademark ‘Tabloid’, a combination of the terms used for the compressed pill, tablet and alkaloid. Doctors prescribed ‘tabloids’ to patients due to the merits of its accuracy and purity; effectively creating a monopoly for Burroughs, Wellcome and Company.

It was after the death of Silas Burroughs in 1895, that Wellcome steered his company towards his own aims. He set up physiological laboratories to produce drugs, including the anti-toxin serum to vaccinate against diphtheria, and later chemical experimentation laboratories in a quest to identify new drugs. Wellcome employed some of the leading scientists in the world to work within his firm, encouraging career progression and the ability to publish findings in academic periodicals free from company supervision. As such numerous breakthroughs in drug development and medical science were attributed to Wellcome’s Research Laboratories including treatments for gas-gangrene, tetanus and production of the first antihistamines and insulin.

L0029860 Pharmacological laboratory, WPRL

[The experimental pharmacology laboratory of the Wellcome Physiological Research Laboratories. 1909.]

 

Stemming from his days in Ecuador and Peru, Wellcome also held a steadfast interest in tropical diseases which presented itself through many of his philanthropic enterprises in Sudanese Africa following the First World War. Visiting Khartoum, Sudan in 1898, Wellcome experienced a war ravaged city, unclean mud hut dwellings, and an array of diseases, including malaria and small pox, and famine. He believed through scientific research and better hygiene health could be improved drastically. Wellcome donated state of the art scientific equipment and research facilities to the Gordon Memorial College in Khartoum as a means to aid the city.

L0025347 Gordon Memorial College.

[Gordon Memorial College, Khartoum, site of the Wellcome Tropical Research Laboratories]

 

The Wellcome Tropical Research laboratories were set up in 1902, run by Dr. Andrew Balfour, and had the initial directive to eradicate malaria in Khartoum. They cleared mosquito breeding grounds, set up a health system and created clean water and sanitation systems and as a result reduced malaria related deaths by almost 90%. Khartoum became the healthiest city in the African continent.

L0025358 Wellcome Archives: Khartoum Laboratories

[Staff at the Wellcome Tropical Research Laboratory, Khartoum. Wellcome is in the centre of the picture (with his white pith helmet on his lap). Andrew Balfour is seated on Wellcome’s right hand side. c.1910.]

In 1913 The Bureau for Scientific Research was established to amalgamate the Physiological Research and Chemical laboratories with research into Tropical Medicine. A museum of specimens, images, artefacts and other material, called the Wellcome Museum of Tropical Medicine and Hygiene, was set up for further research into tropical diseases. This collection has become a foundation for distance learning for low and middle income countries and focuses on teaching medical workers about tropical diseases including malaria, leprosy, and tuberculosis across the world.

In 1910 Henry Wellcome had been granted British citizenship, he founded the Wellcome Foundation Ltd in 1924 and was subsequently knighted in 1932 and awarded an Honorary Fellowship of the Royal College of Surgeons, for his contributions to the medical science and pharmaceutical industries, as well as his philanthropic work studying tropical diseases in Africa, typifying the high level of respect he had achieved within medical science. Upon his death in 1936, he vested the entire share capital of his company in individual Trustees, who were charged with spending the income to further human and animal health. The Wellcome Trust is now one of the world’s largest biomedical charities.

Information and Images taken from:  http://www.wellcome.ac.uk/About-us/History/index.htm