Concluding Thoughts…

We’ve now reached the end of the cataloguing phase of the project, and I thought it would be nice to conclude with some brief final thoughts on what I have seen over the last few months.

The archives here at the Royal London Hospital contain a wealth of information on this disease, of which I have only been able to share a small amount. Over the course of the project I’ve looked at case notes, hospital minutes, photographs, letters, printed leaflets and all manner of other materials, which have revealed the extent of tuberculosis in Britain, and the desperation to find a cure. Thousands of case notes, each detailing the symptoms, diagnosis, and progression of disease in the patient, show how prevalent tuberculosis was. The list of medications given in each of these rarely amounts to anything more effective than cod liver oil and other solutions to ease symptoms, giving a sense of the futility of the battle against tuberculosis without either surgical means or antibiotics. The archives also include letters from people who claim to have found a brilliant cure (and if you pay them upfront, they might tell you what it is! – RLHBH/A/14), as well as dissertations and statistical notebooks attempting a more rigorous approach to curing the disease.

The archives also show something of the social stigma of TB, caused partly through fear of catching the disease, and partly because sufferers were seen as weak. The Frimley Sanatorium Almoner’s Letters (RLHBH/AL/3) are a great record of some of the attitudes towards tuberculosis in British society throughout the early twentieth century. This is a series of correspondence between patients and the almoner (forerunners to social workers) at the hospital, written in the years following their treatment. They reveal a lot about how the patients progressed; some patients reported perfect health for years after treatment and lived to a ripe old age, while others repeatedly fell ill to TB and other chest diseases. But some of the letters also reveal a stigma; quite a few patients sent stern requests that neither letters nor health visitors should be sent to them, while others communicated only through their mothers or other close relatives (one woman begged not to be written to directly, as she feared that her husband would divorce her if he found out she had been treated in a sanatorium!). This series contains many fascinating insights into society at the time, with patients’ writing to request charity, seeking medical advice, or simply providing a complete update on their lives since they last wrote.

The final thing I’ve taken away from this project, which has occurred to me time and time again as I’ve looked at these records, is how lucky and privileged we are compared to even 70 years ago. The archives here include countless photographs and case notes from patients of all ages suffering from various forms of tuberculosis; this includes clinical photographs of children suffering from scrofula, who have gaping holes in their necks following surgery (RLHPP/BAI/5), as well as the letters and case notes of older patients, who may only be in their teens or twenties, who suffered for years before dying from tuberculosis. Procedures such as Artificial Pneumothorax or Thoracoplasty are awful-sounding answers to a problem that nowadays can mostly be solved by tablets. While tuberculosis remains a serious problem elsewhere in the world, the fact that in Britain it barely even registers as a concern shows how lucky we are here, today.

 

I hope you have enjoyed reading this blog as much as I have enjoyed writing it! Although the cataloguing phase is over, the conservation of the records is continuing apace, and our project conservator will be posting here on her progress. If you have any enquiries about records at the Royal London Hospital, tuberculosis-related or otherwise, you can contact us at rlharchives@bartshealth.nhs.uk.

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London Chest Hospital, Victoria Park

Olding ward, London Chest Hospital, c.1925

Olding ward, London Chest Hospital, c.1925. Photograph: Royal London Hospital Archives. RLHLC/P/2/2/7

London Chest Hospital was founded in 1848 by a group of philanthropic bankers and City merchants, many of whom were Quakers, who had witnessed the success of the Brompton Hospital and wished to provide the same service to residents of the City and the East End of London. As a general hospital, The London Hospital was unable to provide specialist care to chest patients, and the other London chest hospitals were too small or too far away to provide services to patients in the east of London.

Initially opening as a public dispensary based in Liverpool Street, it proved an immediate success and limits soon needed to be placed on the numbers of patients treated. Funds were soon raised to build a hospital, and the site next to Victoria Park was purchased as it had extensive grounds so that the hospital could start small and expand.

Postcard showing patients sitting in deckchairs on the front lawn of the hospital 1923

Postcard showing patients sitting in deck chairs on the front lawn of the hospital,  1923. Photograph: Royal London Hospital Archives. RLHLC/P/2/1/4

Amongst the proposed designs for the hospital was a ‘Crystal Sanatorium’ presented by Sir Joseph Paxton, designer of the Crystal Palace for the Great Exhibition. The Illustrated London News described the principles of the building, “in which the purity of the atmosphere should be secured by a process of artificial filtration and an equable and pure temperature… the outer air being admitted by tunnels to the centre of the building”. However, this idea was too expensive to put to use, and instead of a Crystal Sanatorium, the residents of Bethnal Green had to make do with a typical Victorian hospital. (RLHLC/X/17)

Prince Albert laid the foundation stone for the hospital in 1851, and an initial sum of £30,000 was raised to build the hospital. In 1853 the hospital opened with 12 beds, expanding to 80 by the end of the decade. It was a huge success, and by 1862 had treated 9074 out-patients and 442 in-patients. Two further wings were added in 1865 and 1871, providing 160 beds in total.

From the beginning, the mission of the hospital was to treat patients with all chest conditions, not just tuberculosis. No more than half of the beds were to go to tuberculous patients; however, this requirement was relaxed by 1864, as the majority of cases were tuberculous. As you can see from this table, this was still the case in 1924, a year after the hospital clarified with a change of name that it was “The City of London Hospital for Diseases of the Heart and Lungs”.

1924 Inpatients: (All diseases with more than 10 admissions)
315 Pulmonary tuberculosis*
43 *PT and other complication
29 observed for PT, found to have no disease
35 Fibrosis of Lung
30 Bronchitis and Emphysema
29 Mitral Disease
27 Pleurisy, Acute Serous
26 Bronchiectasis
25 Acute Lobar Pneumonia
24 Hypertrophy of Tonsils and Adenoids
19 Auricular Fibrillation
16 Asthma
15 Acute Bronchitis
14 Tuberculous Adenitis, Mediastinal
11 Acute Lobular Pneumonia
11 Acute Tonsilitis
Female patients on the balcony taking air, 1923

Female patients on the balcony taking air, 1923. Photograph: Royal London Hospital Archives. RLHLC/P/2/2/4

Nineteenth century principles of tuberculosis treatment were very different to the later methods that would develop in the sanatoria, and hot, airless wards were the order of the day. Unlike the open shapes of later sanatoria, such as Frimley or Harefield, the London Chest Hospital was built in a standard shape, lacking balconies. As the new ideals took hold, in 1900 two balconies were added. Each could take 8 patients, who remained on balconies day and night regardless of weather; beds were fitted with Mackintoshes to keep patients dry in the rain!

As the twentieth century progressed, the hospital added as dispensary, providing outpatient care to patients in Bethnal Green and Hackney. The hospital maintained a sanatorium, initially in Saunderton, Bucks, then in Camberley, and later in Arlesey. The 1920s brought a new X-ray department, creating about 1000 plates a year in 1925. The surgical ward was out-of-date and unable to meet demands by 1913 – the intervening war delayed improvement, but a new surgical wing was opened in the 1930s as a result of a public appeal. A clinic for breathing exercises was established in 1939, and a physiotherapist specialising in thoracic work was appointed in 1944 .

X-ray Examination Room, C20th

X-ray Examination Room at the London Chest Hospital, C20th. Photograph: Royal London Hospital Archives. RLHLC/P/2/5/1

The hospital was funded by the typical subscription model; unusually, however, local workmen started to club together, contributing a penny each from their weekly wages. These societies frequently donated over £1000 per year, a considerable sum which enabled them to recommend patients. This shows the strength of support the hospital enjoyed from the local community, but also suggests that the patients’ realised that the expense would be too much to bear individually. Appeals were another key feature of the hospital’s fundraising efforts, with adverts appearing on buses and in the press, as well as spoken appeals on the BBC.

Continued growth saw more than 40,000 outpatients treated per year by 1939. During World War II, The London Chest Hospital became an EMS hospital, with a minimum of 75 beds reserved for air raid casualties.

Bomb damage to the exterior front facade of the Hospital, 1941

Bomb damage to the exterior front facade of the Hospital, 1941. Photograph: Royal London Hospital Archives. RLHLC/P/2/8/1

Nurses cheering in the rubble, 1941

Nurses cheering in the rubble, 1941. Photograph: Royal London Hospital Archives. RLHLC/P/2/8/15

 

Medical staff wheeling objects salvaged from the rubble across the bombsite, 1941

Medical staff wheeling objects salvaged from the rubble across the bomb site, 1941. Photograph: Royal London Hospital Archives. RLHLC/P/2/8/16

Bomb damage in a ward in the North wing, 1941

Bomb damage in a ward in the North wing, 1941. Photograph: Royal London Hospital Archives. RLHLC/P/2/8/27

The minutes of the Committee of Management tell the next part of the hospital’s story:

28 March 1941: The Secretary reported that on the night of March 19th the Hospital buildings suffered severe damage through enemy action, the Pathological Laboratory and Chapel being completely demolished, one section of the Nurses’ Home destroyed, the North Wing of the hospital so severely damaged that it will have to be taken down as a dangerous structure, and the roof of the South Wing completely gutted by fire from incendiary bombs.

There were in the Hospital at the time 85 patients and approximately 60 staff.

There were no deaths and the staff in spite of injuries from broken glass etc. in a very short time removed the patients to safety in the Parmiters School nearby. Five nurses were buried in the debris of the Nurses’ Home and were rescued, having sustained only minor injuries.

The Vice-Chairman reported that members of the House Committee and Medical Staff attended the hospital the following morning and at an Emergency Meeting instructed the Secretary to endeavour to re-establish as soon as possible in some portion of the Hospital the Out-Patient Department, First Aid Post and Special Clinics.

The quest to re-establish the hospital suffered a setback in May, as the hospital was bombed again and all the repair work was destroyed. However, the Outpatient Department, and clinics such as the Tuberculosis Dispensary, were back at work soon after the bombing, and other patients were sent to the county branch at Camberley while re-building took place. By October patients were back at the hospital, where some rearrangement had taken place; wards now occupied the ground and first-floors, and first-floor patients were moved into the basement each evening. Surgery was slower to re-establish, although minor surgery was allowed by 1943.

The minutes also reveal some of the measures taken to prevent the spread of tuberculosis within the hospital. They were not always successful, as in 1946 some nurses were found to have contracted the disease, but there was no systemic reason found to explain why this occurred. Tuberculosis patients were kept to their own wards, with no shared corridors with other patients. Medical staff were x-rayed on arrival at the hospital, and routinely re-scanned every 1-6 months depending on their Mantoux status (which would indicate if they had been exposed to tuberculin). Nurses, particularly from rural Ireland or Wales, who were shown not to have been exposed to tuberculosis were also not allowed to work on the tuberculosis wards.

In 1948, as part of the creation of the NHS and the abolition of Voluntary Hospitals, London Chest Hospital amalgamated with Brompton Hospital for the purposes of being designated a Teaching Hospital. As the century progressed, and the need for tuberculosis treatment lessened, the hospital expanded its focus on other diseases of the chest, such as cardiology. Brompton and The London Chest Hospital worked together until the 1990s, when the London Chest Hospital was aligned instead with the Royal London Hospital, located in nearby Whitechapel. In April 2015, services from the London Chest Hospital moved to St Bartholomew’s Hospital (Barts), within the same administration group, and the building was sold.

Female patients taking the air on the cleared site of the ground floor of the North Wing, London Chest Hospital, c. 1948. Caption "But for an air raid these patients at the London chest Hospital might have been three storeys up. As it is they are taking the air on the ground floor on the cleared site of the North Wing that was destroyed in 1941. " New York Times Photos, 2, Salisbury Sq., Fleet Street.

Female patients taking the air on the cleared site of the ground floor of the North Wing, London Chest Hospital, c. 1948. Caption “But for an air raid these patients at the London Chest Hospital might have been three storeys up. As it is they are taking the air on the ground floor on the cleared site of the North Wing that was destroyed in 1941. ” New York Times Photos, 2, Salisbury Sq., Fleet Street. Photograph: Royal London Hospital Archives. RLHLC/P/2/2/12

Sources:

RLHLC/X – Miscellaneous Records

RLHLC/A/2 – Minutes of the Committee of Management

Harefield Hospital

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Harefield Sanatorium at night (RLHHF/P/1/1/30). The large, curved balconies allowed patients exposure to light and air.

Harefield Hospital, which celebrates its centenary this year, is renowned around the world as a cardiac centre, pioneering heart and lung transplants in the 1980s. Its proud history as a hospital for the heart and lungs includes its establishment as the county sanatorium for Middlesex.

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Australian patients celebrate Christmas in the Number 1 Australian Auxiliary Hospital, Harefield Park (RLHHF/P/1/2/9). The wards were in wooden pavilions, clustered around the old house. Photograph by Printing-Craft. Ltd, London and Mansfield

Before a hospital stood on the site, Harefield Park was home to a succession of wealthy families. Upon the outbreak of the First World War, the owners provided use of the manor to Australian forces, and the No. 1 Australian Auxiliary Hospital was therefore established in 1915, marking the beginnings of Harefield Hospital, in a very different form. The manor house was converted into doctors’ accommodation and wooden pavilions were constructed in the grounds to house the wounded soldiers.

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“A Block” at Harefield Sanatorium. (RLHHF/P/1/3/28). The wooden pavilions of the military hospital were repurposed into wards for the sanatorium, imaginatively named A, B, C, D, E, and F Block. Note the verandas, which allowed patients to enjoy outdoor treatment.

After the war, Middlesex County Council purchased the estate for use as a County Sanatorium.  Each county was required to provide sanatorium treatment for tuberculosis sufferers, but the onset of WWI had delayed this provision within Middlesex. The site was in poor condition, and the huts used for the Australian patients were carefully taken down and rebuilt to provide six pavilions for the patients of the sanatorium, with south-facing verandas in order to provide sunlight and fresh air.

The hospital provided 250 beds for tuberculosis patients, and fulfilled the requirements for rest, open air, exercise and good food. Male and female patients were segregated, with the men’s pavilions located half a mile from the site entrance to ensure that no mixing took place! There was also accommodation for children, which included a school to minimise the disruption to their education caused by their illness.

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The new hospital buildings under construction. (RLHHF/P/1/3/33). You can see the curved wings beginning to take shape.

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An aerial view of the completed hospital, showing the ‘crossbow’ design of the wings. (RLHHF/P/2/1/1). This  structure remains today, though there have been many additions since 1937. Photograph by Photoflight Limited, Elstree, Herts.

Although the wooden pavilions provided a quick solution to the need for a county sanatorium, the need for a permanent building was soon recognised, and building work commenced in 1935. The new building opened in 1937, and is the same building (with some additions) that stands today.

A ‘crossbow’ design with three large, south-facing, balcony-lined curves, the building was designed on sanatorium principles that allowed for open air and maximum sunlight. Large open spaces were part of the design, and the hospital was built with the latest treatment methods in mind, providing a modern surgical theatre and an X-ray department for the administration and monitoring of artificial pneumothorax and similar procedures. The farm, a feature since the days of the Australian hospital, remained; it allowed the hospital an element of self-sufficiency through the production of eggs, poultry and produce, and remained an important part of the sanatorium until 1960.

The sanatorium regime followed similar principles to those seen at other sanatoria, such as Frimley. Patients were segregated, and followed strict rules. They were allowed out of bed for progressively longer periods to walk in the grounds and assist on the hospital farm and orchards, and some were able to go shopping on behalf of their fellow patients. The male patients were particularly good at breaking the rules; in the days of the pavilions, they would often sneak away to the local pub, and they remained adept at getting away even after the permanent buildings were constructed.

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A surgeon performs an artificial pneumothorax procedure at Harefield Hospital. (RLHHF/P/2/6/2). A British Official Photograph distributed by the Ministry of Information.

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A physiotherapy class for male patients with pulmonary tuberculosis. (RLHHF/P/1/5/5). These stretches were designed to help patients recover strength in their lungs following the illness and treatment.

Harefield led the way in other methods of tuberculosis treatment; it is thought to be one of the first places in Britain to administer artificial pneumothorax, and soon gained a positive reputation for a high rate of success in tuberculosis treatment. Occupational therapy was provided from 1938, with printing, leather working and book-binding facilities provided. During WWII, physiotherapists at the hospital introduced popular postural techniques to assist recovery following surgery, minimising the deformities caused by some of the more extreme interventions such as thoracoplasty, which involved removing parts of the ribs.

The Second World War saw Harefield transformed into an Emergency Medical Service Hospital, taking on some of the patients evacuated from St. Mary’s Hospital. It also became the site of a National Thoracic Unit, performing surgery of the chest. Four wards in the main block were allocated to sanatorium patients, but others were turned over to military personnel, patients with chest injuries, and non-tuberculous patients in need of thoracic surgery. Over the course of the war, the Thoracic Unit had 1804 admissions, and 501 major non-tuberculous thoracic operations were carried out. This diversification led to heated debates over the future of the hospital once the war was over; was it to return to its functions as a (still much in demand) sanatorium, should it retain the highly regarded Thoracic Unit for non-tuberculous patients, or should it become a general hospital, better suited for training nurses. Ultimately, tuberculosis remained a high priority for the hospital, but it also became the site of a Regional Thoracic Surgical Unit.

In 1947, Harefield took part in clinical trials of Streptomycin, the first antibiotic effective against tuberculosis. In the early days it took months for the medicine to work, giving bacteria time to become resistant, so sanatorium treatment and surgical intervention were often still required. Other drugs which were developed in the 1950s overcame these problems, and finally fewer patients were being treated for less time. The need for tuberculosis beds declined and the Thoracic Unit grew in importance, adding cardiovascular care to its specialties and pioneering heart and lung transplants within the UK.

 

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Patients on the balconies of Harefield Sanatorium (RLHHF/P/1/1/151A). Fresh air was an important element of tuberculosis treatment before antibiotics were found to treat the disease. The balconies were later walled off and incorporated into the wards of the present day hospital.

Harefield’s time as a sanatorium was relatively brief; however, the records still have important lessons to teach us about tuberculosis treatment. Sadly, the case notes of this institution are not included in the archive, but the archives contain information about the building itself, including plans and maintenance records. As a purpose-built sanatorium, the design and equipment chosen reveal attitudes towards the most effective means of treatment in the 1930s, with the emphasis on open air and surgical procedures. Tuberculosis may be only a small part of the overall story of Harefield Hospital, but its influence is evident in both the design and the thoracic specialties of the present day hospital.

Sources:

Royal London Hospital Archives, RLHHF, ‘Records of Harefield Hospital’

Mary P. Shepherd, Heart of Harefield: The Story of the Hospital (1990).

A Sanatorium in focus: Brompton Hospital Sanatorium, Frimley

“…idleness, the ennui, and the economic waste which are too often the reproach of Sanatorium treatment have no place at Frimley.” (RLHBH/A/20/5)

An aerial view of Frimley Sanatorium. (Photographer unknown).

An aerial view of Frimley Sanatorium. Note the ‘X’ shape of the hospital, and the surrounding fields which were cultivated by patients. (Photographer unknown). RLHBH/P/2/7/2

 

Frimley Sanatorium was part of what was then called the Hospital for Consumption and Diseases of the Chest, Brompton, and opened in 1905 to provide a rest cure and treatment to tuberculosis sufferers in a rural setting. The objectives of the sanatorium were threefold; to submit early cases to treatment in “a dry and balancing climate for several months, with a view to arresting the disease”; to educate patients in hygienic principles; and to provide a convalescent home for other patients treated at Brompton Hospital (RLHBH/X/11). The sanatorium itself was built according to the best principles of the day, with four wings in an X shape so that all wards were south-facing, with plenty of large windows and balconies in order to support open air treatment, and open grounds which could be worked on by patients as part of their treatment.

Patients working on the construction of a reservoir at Frimley Sanatorium. RLHBH/P/2/9/6. Click to see the completed work (RLHBH/P/1/2/10).

Frimley took the most promising cases from Brompton, although it soon allowed some direct admissions from paying patients. Patients came from all walks of life, and included policemen, military men, teachers, labourers, nurses and physicians, singers, and even a dancer at the Moulin Rouge! The sanatorium was open to male and female patients, although the preference was for male patients. Treatment took several months to complete, and it was felt that women were more likely to leave early to attend to their families. Male patients were also preferred as they would be the main breadwinner in their family; poverty was a major cause of disease due to poor food and living conditions, so a healthy man to lead the household was seen as a good way to ensure that the whole family did not succumb to illness.

Rules for patients at Frimley Sanatorium (1920/30s)

Rulebook for patients at Frimley Sanatorium, showing the strict daily routine (1920/30s). Click to enlarge. (RLHBH/A/1/17/2)

Rules were strict; a letter welcoming new patients (RLHBH/AL/4/3/1) acknowledged that they “may seem tiresome at first”, but stated that these were the rules which were to be the basis of the patient’s future life and health. Male and female patients were segregated unless at rare ‘mixing’ events, outside visits were strictly regulated, and the provided timetables were to be strictly adhered to. These rules were firmly enforced, and patients were discharged from treatment for disobedience. However, patients found ways around this discipline, as the following extract from a patient magazine suggests:

 

 

A Two Minute Puzzle

You’re on Grade Four. After a terrific mental struggle you make all arrangements to say good-bye to your ‘mixer’ one evening at 9.30 on Chobham Ridges. The glad moment arrives. You clasp the dear, unreluctant, tenebrous, magic form in your arms. You say, “Darling! At last we are together.” And then you discover it is Sister —.

What would you do?

What would she do?

(RLHBH/X/14)

Rulebook for patients at Frimley Sanatorium, showing the graded exercise regime. Click to enlarge. RLHBH/A/1/17/3

Rulebook for patients at Frimley Sanatorium, showing the graded exercise regime. Click to enlarge.
RLHBH/A/1/17/3

Treatment at Frimley Sanatorium was based on a principle developed by its first Medical Superintendent, Dr Marcus Patterson, based on ‘auto-inoculation’, the inaccurate theory that through regulated exercise, a patient could develop a resistance to the bacterial products which tuberculosis released into their bloodstream. This belief, coupled with fears that too much bed rest might lead to idleness in the working class patients for whom Frimley cared, lead to the creation of a system of ‘graded exercise’ practised at Frimley Sanatorium.

Male patients digging as part of their exercises; a key part of the treatment at Frimley Sanatorium. RLHBH/P/2/9/3

Male patients planting pillars as part of their exercises; a key part of the treatment at Frimley Sanatorium.
RLHBH/P/2/9/3

Female patients at work as part of their treatment at Frimley Sanatorium. RLHBH/P/2/9/4

Female patients at work as part of their treatment at Frimley Sanatorium.
RLHBH/P/2/9/4

Patients would remain on absolute bed rest until they showed suitable improvement; they would then begin to walk in the grounds, building up their miles until they were sufficiently fit to work. At this point, they would begin to perform manual tasks which supported the upkeep of the sanatorium, building up in intensity until they were at the top grade, and ready to leave. Male and female patients would work on outdoor maintenance tasks, carrying buckets of soil, wheeling barrows, mowing lawns, caring for the garden, and maintaining a kitchen garden which was to provide the sanatorium with a supply of fresh vegetables. There was even a pig farm, and serious consideration of taking on chickens during World War II. One of the earliest tasks completed by the patients of the hospital was the construction of a reservoir; a remarkable task which featured in a series of postcards, expressing delight at the surprising work done by the consumptives.

Fresh air was another component of treatment provided at Frimley, with patients advised that “You will never beat T.B. if you can’t stand a draught.” (RLHBH/AL/4/3/1). Large windows and balconies meant that patients were constantly subjected to the open air, in common with the belief derived from the Swiss sanatoria that cool fresh air was the cure for tuberculosis. This was probably more helpful than the earlier belief that patients should be kept in stuffy, closed rooms, which meant that the bacteria could thrive. Letters written to the Almoner of the hospital by patients reported that some never slept with a closed window, even decades after they received treatment, which shows how well this advice was drilled into them!

 

From the 1920s, in line with advances in tuberculosis treatment, the new Medical Superintendent Dr Wingfield encouraged the use of surgical treatments such as artificial pneumothorax in certain cases; the patient magazine referred to earlier frequently mentions the refills that patients would have required to keep the cavity full of gas.

The sanatorium regime didn’t stop once a patient had left Frimley; an advice booklet was given to leaving patients, advising on the best kinds of employment (outdoors), housing (an uncrowded area with a southerly aspect was to be preferred), and home décor (no heavy curtains or ornaments). Smoking was permitted only after meals, so as not to disrupt appetite. (RLHBH/A/14/74).

When the sanatorium opened, it was confidently declared that “this and similar Institutions will still fulfil an essential purpose even should the advance of medical science lead to the discovery of some agent more directly affecting the activity of the organism of the disease”. (RLHBH/A/14/69) This was not to be, and due to effective antibiotics, the need for a sanatorium had diminished by the 1960s; under the leadership of Dr Aylmer Foster-Carter, Frimley transitioned into a convalescent hospital, looking after post-operative cardiac and respiratory patients from Brompton Hospital, London Chest, and National Heart Hospital, and other London Teaching hospitals, until its eventual closure in the 1980s.

An exterior view of Frimley Sanatorium, showing the garden which patients planted and maintained. Note also the beds visible on the balconies, which provided fresh air for patients on bed rest. RLHBH/P/1/2/9

An exterior view of Frimley Sanatorium, showing the garden which patients planted and maintained. Note also the beds visible on the balconies, which provided fresh air for patients on bed rest. (Photographers: The Qualis Photo Co. Ltd., for Brompton Hospital, c.1920s)
RLHBH/P/1/2/9

World Tuberculosis Day

Image: Royal London Hospital Archives. (RLHPP/BEA) Christmas Seals from around the world, 1936-1937

Image: Royal London Hospital Archive. (RLHPP/BEA)
Christmas Seals from around the world, 1936-1937

On this day in 1882, Robert Koch announced his discovery of the TB bacillus. In commemoration, March 24th has been designated World Tuberculosis Day, a day to promote awareness of the continuing global TB epidemic, and call on governments, affected communities, civil society organizations, health-care providers, and international partners to join the drive to reach, treat and cure all those who are ill today.

As part of our collections we have a collection of Christmas seals, used around the world in the twentieth century to gather funds for treating tuberculosis, which I thought it would be ideal to share on this day of global awareness.

Christmas seals are like rather like stamps, only they don’t pay for postage, but raise funds for tuberculosis charities. The idea was first developed in 1904, by a Danish postal clerk, Einar Holbøll, and over 6 years enough money was raised to build a sanatorium, the Christmas Seal Sanatorium (Julemærkesanatoriet) in Kolding. The idea soon spread through Europe and from there, around the world.

Image: Royal London Hospital Archives. (RLHPP/BEA) Christmas Seals from Denmark, 1905-1938

Image: Royal London Hospital Archives. (RLHPP/BEA)
Christmas Seals from Denmark, 1905-1938. Number 5 shows the sanatorium which was built with the proceeds of these appeals.

Our collection comes courtesy of Dr. John R Beal, a physician who worked at the Brompton Hospital, as a tuberculosis officer around the north of England, and as officer in charge of the tuberculosis centre in Pune during World War II. He was a keen collector of Christmas seals, which his son has kindly been donated to our archives.

Image: Royal London Hospital Archives. (RLHPP/BEA) Christmas Seals from Poland, 1931-1936

Image: Royal London Hospital Archives. (RLHPP/BEA)
Christmas Seals from Poland, 1931-1936

Image: Royal London Hospital Archives. (RLHPP/BEA) Christmas Seals from Italy, 1930s

Image: Royal London Hospital Archives. (RLHPP/BEA)
Christmas Seals from Italy, 1930s

The seals come from all over the world, and I think that one thing they really bring to light is the truly global impact of tuberculosis; the drive to create and purchase them can only have come from communities which were affected by this deadly disease. The images used in these stamps are mostly Christmas themed, although several show nurses caring for children, sanatoria, or anti-tuberculosis slogans; the only way you can tell that they are about tuberculosis is the double-barred cross of Lorraine which features on many of them. This symbol was chosen as the symbol of the international fight against tuberculosis at a conference in Berlin in 1902, and the fact that it was recognisable enough to act as shorthand for tuberculosis on these stamps suggests that the cause was very well-known, much like the pink ribbon or similar charity symbols nowadays.

Image: Royal London Hospital Archives. (RLHPP/BEA) Christmas Seals from Japan and Korea, 1931-1936

Image: Royal London Hospital Archives. (RLHPP/BEA)
Christmas Seals from Japan and Korea, 1931-1936

Tuberculosis may have fallen away from our awareness in the UK, but it is still a very real issue for many around the world. In 2013, 9 million people fell ill with TB and 1.5 million died from the disease. These stamps act as a reminder that tuberculosis has always been a global issue; let’s hope that someday it will be considered a part of global history.

Clockwise, top left-r. France, USA (4 set), South Africa, Great Britain, Finland, Germany.

Image: Royal London Hospital Archive, RLHPP/BEA.
Clockwise, top left-r: France, USA (4 set), South Africa, Great Britain, Finland, Germany.

The Hospital for Consumption and Diseases of the Chest, Brompton

The first part of the project has been to look at records from The Hospital for Consumption and Diseases of the Chest, Brompton, in particular the hospital’s sanatorium at Frimley. Over the next few posts, I’m going to be sharing some of what these records can tell us about the treatment of tuberculosis.

RLHBH/P/1/5/1

Image: Royal London Hospital Archives. Photograph showing the entrance to Brompton Hospital. Photographer: Bedford Lemere & Co.

The records of the Royal Brompton Hospital cover much of the history of the hospital, which was one of the first in London to admit patients with tuberculosis. Many notable physicians, including William Paton Cleland, Sir John Forbes, and Sir Richard Douglas Powell, worked there, and the hospital was responsible for treatments such as the ‘Brompton Cocktail’, and the first mass radiology survey in England in 1926. While the hospital now deals with all heart and lung conditions, for much of its early history the key focus was on tuberculosis.

RLHBH/A/1/1

Image: Royal London Hospital Archives. Letter from Philip Rose, about the foundation of Brompton Hospital (12 Jan 1841)

The Hospital for Consumption and Diseases of the Chest, Brompton was founded in 1841 by Philip Rose (later Sir Philip Rose), a young solicitor who was disappointed to find that a clerk in his firm had been refused admission to any hospital to treat his consumption. The Hospital initially opened with a small number of beds in Manor House in Chelsea and with an out-patient department at Great Marlborough Street; demand soon outgrew the available space, and funds were raised to build a new building for the hospital, with the foundation stone laid by Prince Albert at a ceremony in 1845.

The hospital continued to expand, supported by figures such as Charles Dickens, Benjamin Disraeli, and the famous singer Jenny Lind, who performed an in concert to raise £1606 for the Building Fund (equivalent to over £90,000 in today’s money). A sizeable donation came from Cordelia Read, who left her personal estate to the hospital, including valuable paintings by John Opie, to the surprise of her family. After a long dispute, the hospital received £100,000 which was used to build a new extension in 1882. The collection of paintings was used to decorate the boardroom. (Papers relating to this bequest can be found in the archives with the reference number RLHBH/A/14/28 and RLHBH/A/14/40).

RLHBH/P/1/5/2

Image: Royal London Hospital Archives. Photograph showing the new extension building of Brompton Hospital, built in 1882 thanks to a bequest from Cordelia Read. Photographer: Bedford Lemere & Co.

By 1879 the hospital had 368 beds, and dealt with thousands of patients (in- and out-) each year. Although primarily associated with tuberculosis, Brompton Hospital had a number of departments which dealt with other diseases of the chest. A throat department was started in 1889, and expanded in 1922, and a radiology department was instituted in 1900, and expanded in 1925. Several attempts were made at creating a sanatorium for patients who required long-term inpatient treatment; a hospital at Bournemouth was used initially, but problems with transportation made it unsuitable. In 1904, a purpose-built sanatorium was opened at Frimley; I’ll look at this more closely next time. Moving away from respiratory ailments, a cardiac department opened in 1919, and in 1934 a physiotherapy department opened, initially as a “breathing exercises” department; by 1948, the department had expanded to include 6 full-time and one part-time ‘instructresses’, due to the success of these techniques in patients with chest conditions.

In 1948 Brompton Hospital came under the control of the NHS, and merged with the London Chest Hospital to become the Hospitals for the Diseases of the Chest. Thanks to the advent of effective antibiotics, tuberculosis became less of a concern for the hospital, and the emphasis began to shift to other areas of lung and heart medicine. A number of administrative changes took place as hospitals joined and left the NHS Trust, or administrative unit, reflecting changing expertise and priorities within the organisation. In 1971 the Hospitals for Diseases of the Chest merged with the National Heart Hospital, which was closed and moved to Brompton in 1991. This merger formed the National Heart and Chest Hospitals, later known as The Royal Brompton National Heart & Lung Hospitals. In 1998 the Royal Brompton Hospital joined up with Harefield Hospital creating The Royal Brompton and Harefield NHS Trust, which is still the largest cardiothoracic centre in the UK.

L-R; RLHBH/M/1/1, RLHBH/M/1/97

Image: Royal London Hospital Archives. Two case books, from 1862-4 and 1918, containing information on patients’ symptoms, diagnosis, and progress. Note the diagrams of the lungs, showing affected areas.

The records held at the Royal London Hospital Archive for the Royal Brompton Hospital includes large numbers of patient case notes. The information recorded in these volumes includes notes on the health of the rest of the family, reflecting nineteenth-century beliefs that tuberculosis was in some way hereditary, whereas we now know that more than one incident in the same family was due to proximity. Notes on treatments given, including the growing use of artificial pneumothorax and other surgical interventions from the 1920s, also provides us with details regarding the changing treatment of tuberculosis. The careful collection of data on temperatures, pulses and weight show us how a diagnosis was reached and the progress of the disease was monitored. Diagrams of lungs are used, with problem areas indicated, which gives us hints as to how infected areas were identified before the routine use of x-rays to image patients’ chests.

The records also include papers and volumes relating to the administrative history of the hospital; a collection of deeds, financial records, and minute books, alongside correspondence, appeal files, press cuttings and photographs, which reveal how the hospital grew, adapting to the changing medical landscape.

In the pre-NHS days, the hospital was reliant on donations and subscriptions for revenue, and often ran under-capacity due to lack of funds. New equipment or facilities could only be provided through voluntary contributions. When a new X-ray department was required, appeals were made to City Companies for their help, raising several hundred pounds, a considerable sum in those days. In return for their support, subscribers and significant donors were granted the right to recommend patients; in fact, patients required recommendations in order to obtain treatment, and could be refused treatment on subsequent occasions if they failed to properly thank the subscriber who recommended them.

Fundraising appeal literature reveals some of the attitudes people had towards tuberculosis. During the First World War, the appeals took on a patriotic approach, requesting assistance for the British, French and Belgian soldiers being treated at the hospital. One such appeal described Brompton as “…the Fort or Entrenchment of those who are being attacked by the Disease. Their only hope of being saved is to keep under cover of the Institution until the attack of the Enemy has spent itself…” (RLHBH/A/20/3). Peacetime materials took a different approach, highlighting both the duty of the well to care for the ill, and the universal risk of tuberculosis. Several leaflets emphasis this with taglines like “Consumption respects neither persons nor classes” and paragraphs stating that “…at any time, you, or someone near and dear to you, may have cause to be grateful for the skill with which the doctor has effected a cure as a result of the knowledge obtained due to the work of the hospital.” These leaflets reveal a lot about the undiscriminatory nature of the disease, and the dread which people must have had of catching it; comparing it to the bombardment of trench warfare may seem extreme, but it shows us how frightening it must have been to suffer from tuberculosis at the time.

Clockwise spiral, from left: RLHBH/A/20/25/2, RLHBH/A/20/14/6, RLHBH/A/20/3, RLHBH/A/20/27, RLHBH/A/20/10

Image: Royal London Hospital Archives. Examples of Brompton Hospital appeal literature, with leaflets, posters and press adverts requesting donations.

Tuberculosis and its treatment: a short history

Before beginning this project, my ideas about tuberculosis had mostly been informed by period dramas; a character looks a little ill, starts coughing up blood, and inevitably dies soon after. The reality, of course, is very different.

Tuberculosis is not just confined to the lungs, and while it is fatal in approximately 50% of cases if left untreated, it wasn’t the instant death sentence I had assumed it to be. It is also not a disease of the past; tuberculosis is still a major problem in developing countries, and has been declared a global health emergency by the World Health Organisation. According to a recent report from the WHO, in 2013, an estimated 9 million people developed TB and 1.5 million died from the disease.

Plate V; Lungs of a young man who died of Tuberculosis 1834 Wellcome L0074280

Illustration showing the lungs of a young man who died of Tuberculosis 1834. The illustrations show the large abcesses which formed as a result of infection. [via Wikimedia Commons]

  So what is tuberculosis? Historically known as consumption or phthisis, TB is a widespread infectious disease, spread through coughs, sneezes, and sputum, and connected with overcrowding and malnutrition. While it most commonly affects the lungs (referred to as pulmonary tuberculosis), it can affect other areas of the body. Most infections are latent, meaning the disease cannot be spread from infected patients, though one in ten of these cases will progress to the active disease. It affects the body by causing the formation of granulomas, in which the central cells die, causing lesions, fibrosis and cavities.

The cause of tuberculosis was unknown for much of the nineteenth century, though there was much speculation over what might be responsible (culprits such as ‘bad air’, ‘damp soil’, and ‘moral culpability’ were suspected); and doctors across Europe disagreed about whether the disease was infectious or hereditary until the 1880s, when Robert Koch identified the responsible bacterium.

Even after the cause was identified, until effective antibiotics were discovered, treatment of tuberculosis in the United Kingdom was difficult. Hospitals in the nineteenth century were seen as places of restoration, run as charitable organizations. The expense of treating a chronic disease, and the low hopes of a favourable outcome, meant that they were reluctant to take on consumptive patients. In London, five specialist consumption and chest hospitals existed, one of which was the Hospital for Consumption and Diseases of the Chest, Brompton, founded in 1841, but these hospitals struggled due to lack of funds to treat as many patients as they had hoped.

The twentieth century saw the development of the sanatorium, which provided a structured regime of rest and good nutrition allowing patients to recuperate and fight off the disease. Despite their popularity, these institutions are not thought to have had much effect on recovery rates, especially since they tended to only treat the patients with the best prognosis. Dispensaries were also established, which could provide outpatient care so that sufferers didn’t have to leave their homes and work for extended periods of time.

Pneumothorax apparatus, London, England, 1901-1930 Wellcome L0058223

Apparatus used to deliver an artificial pneumothorax, a common surgical treatment for pulmonary tuberculosis in the early C20th [via Wikimedia Commons]

From the 1920s, surgical treatments such as artificial pneumothorax became popular with British doctors. These procedures would collapse the lung, filling the cavity with gas, to ‘rest’ the lung and allow lesions to heal. These, and other unpleasant-sounding treatments, were never really subject to any evidence-based scrutiny, but don’t appear to have been effective as cures. They were finally replaced by medical solutions, with the discovery of antibiotics effective against tuberculosis in 1944 (streptomycin), 1957 (isoniazid), and 1972 (rifampin). BCG inoculation programmes were slow to develop in the UK, but have further helped to reduce the incidence of the disease.

Tuberculosis; death rates Wellcome L0011463

Graph shows the decline in death rates from tuberculosis between 1861-1931; before the advent of effective antibiotics. [via Wikimedia Commons]

The disease had been in slow decline throughout the UK throughout the twentieth century (beginning as early as 1840 in England) due to improvements in living standards and better nutrition; effective chemotherapy dramatically accelerated the decrease of tuberculosis, and raised hopes that the disease may finally be eradicated. This optimism has proven to be short-lived. While TB is now rare in the UK, the rise of drug-resistant strains of the disease, poor living conditions in developing countries, and high rates of HIV, have led to a global resurgence in infection rates. The quest to eradicate the disease continues.

Sources:
Thomas Dormandy, The White Death: A History of Tuberculosis (London, 1999)
F B Smith, The Retreat of Tuberculosis: 1850-1950 (London, 1988)
Wikipedia, ‘Tuberculosis’, http://en.wikipedia.org/wiki/Tuberculosis
Wikipedia, ‘History of Tuberculosis’, http://en.wikipedia.org/wiki/History_of_tuberculosis
WHO Global Tuberculosis Report 2014 http://www.who.int/tb/publications/global_report/en/