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/

Introduction to “The Fight Against Tuberculosis” Project

This blog has been created alongside a project to catalogue records relating to tuberculosis at the Royal London Hospital Archives. This archive contains the records not only of the Royal London Hospital, but of the London Chest Hospital, the Royal Brompton Hospital (including Frimley Sanatorium), and Harefield Hospital. These hospitals provided treatment for patients with chest complaints, particularly tuberculosis. The records held at the archives include case notes, rules for patient’s behaviour, and letters from the patients; and provide insights into how this serious condition was treated in an age before effective antibiotics.

The aim of this project is to examine these records in much more depth than before; and on this blog I will be sharing some of the interesting records, collections and stories that I find over the next few months.