Friday, 24 June 2016

Progress of the Norman Dott Project.

     Time has flown since my first day as a cataloguing archivist for our project ‘Cataloguing Norman Dott’s neurosurgical case notes (1920-1960)’, and it has now been five months since I started cataloguing the case notes. As of today Friday 24th of June, I have catalogued 3,584 case notes using the XML editor Oxygen, which represents an average of 36 per day. If we take into account the case notes catalogued by other archivists, interns and volunteers, we reach an impressive total number of 26,840 records! We are not out of the woods just yet though: I still have around 19 boxes of case notes to catalogue. As the deadline for the project is rapidly approaching, the cataloguing pace has to increase, however we are ready to rise to the challenge.

Print of X-ray with graphite detail mounted on board (PR1.48)

     Working with the Norman Dott collection has been a very enriching experience. I have come across a wide array of material: fascinating photographs and X-ray of medical conditions, graphic yet beautiful clinical drawings, touching postcards from patients warmly thanking Norman Dott for his care… Moreover, the fact that the collection spans four decades of the 20th century – from the early 20s to the early 60s – means that while cataloguing the case notes I have been able to indirectly ‘witness’ the evolution of medicine, with increasingly precise diagnoses thanks to new techniques and increasingly efficient treatments. The records are also full of fascinating human adventures: uplifting miracle recoveries, incredible war stories, impressive medical prowess, as well as tragic accidents (especially traffic accident from the 50s on) and obsolete procedures now viewed as mistakes.



Clinical drawings of an acoustic neuroma operation (PR2.21345) (all personal details have been redacted)
     It is now time to start thinking about the next step: the delivery of the online catalogue that will enable the public to actually see and use the collection. However, the case notes contain a lot of confidential and sensitive data, and we have to be careful in our approach. There will be two catalogues: a redacted version where all the information that could possibly identify a patient has been redacted, and an unredacted version for users who obtained the authorisation to view this information. Ideally, the redacted version would be a public catalogue that everyone would be able to see on ArchivesSpace, with a webpage specifically dedicated to the project – see the Towards Dolly project, also based at the Edinburgh’s Centre for Research Collections and funded by the Wellcome Trust's Research Resources scheme. The delivery of the unredacted catalogue will be somewhat more complicated as access will be severely restricted. One solution would be to only let users search it at the CRC under LHSA archivists’ supervision, on an access-restricted laptop from which it would be impossible to export any data. 

     The online delivery of the catalogue and its publicizing represent another aspect of the project and will bring different challenges that promise to be equally interesting. 


Aline brodin, Project Cataloguing Archivist for the Norman Dott project. 

Friday, 17 June 2016

'Blood Connects Us All' - World Blood Donor Day 2016

This week saw us celebrate World Blood Donor Day, an international celebration of the miracle of blood donation and transfusion. The theme for this year was the idea that ‘blood connects us all’. In this week’s blog Alice examines how that sentiment was quite literal in the early days of blood transfusion, and how the celebration of donors plays a central role... 

When we consider what an integral role blood transfusion plays in modern medicine, it’s surprisingly to think about how new the practice is. Although interest in the idea is evident as far back as the 17th century, it wasn’t until the late 19th century that practitioners began to experiment with it in a more serious way.

There were a number of factors that made blood transfusion a fairly impossible procedure to carry out. Firstly, it wasn’t until Karl Landsteiner identified the different blood groups in 1900 that the interactions between these blood types were understood. He established that if a transfusion of an incompatible blood type is given, there can be fatal consequences as the two sets of cells attack each other. Landsteiner’s discovery minimised this risk.

Andrew Crosbie demonstrating sterilization methods
[GD14A/4/12]

 A second barrier to blood transfusion becoming an established procedure was the problem of finding a suitable donor. With no central register of donors this had to be done on a patient-by-patient basis, and often family members and friends were asked first. Even if a compatible donor was found, they would then have to be brought to the patient’s side – quite literally, that is, for the biggest barrier to successful transfusions was that of clotting. In modern medicine, anticoagulants are added to blood to prevent clotting and allow blood to be stored and transported, but earlier problem-solvers took a much more hands-on approach. Donor and recipient would have to lie alongside one another, with the donor’s “left arm grasping the patient’s left arm well above the elbow”, and the giving and receiving veins actually stitched together. This must have been a very distressing experience for all involved, not least impractical and dangerous, and early blood donors would probably understand more than most the sentiment behind ‘blood connects us all’…

Donors in the Clinical Laboratory being supervised by Dr McRae (Director) and Miss Wilkinson.
[GD14A/4/6]

Thankfully, huge leaps forward were to be made over the years: swift transfers using syringes went some way towards progress, and wax-lined containers such as the ‘Kimpton tube’ reduced the need for donor and recipient to be in the same room together. Clotting remained very much an issue, however, and as there was still no possibility of the blood banks that we know, finding available and compatible donors was a huge problem.

Local attempts to mitigate this began with a man called J. R. Copland. In January 1930, horrified to learn that a friend’s wife had died because no blood donor could be found in time, Copland made the first moves towards establishing a register of donors who could be relied upon in times of need. Copland managed to enlist twenty-four individuals within two months but this was not nearly enough. There were still too many instances when donors could not be fetched in time, and medical staff and students of the Royal Infirmary of Edinburgh had to step in often instead.

J.R. Copland
[GD14A/3/20]
Some of these students had already recognised the need for a register of donors and made their own attempts to address this. Also in January 1930, three of them – D.M. Blair, A. Desmond Stoker and W.I.C. Morris – proposed to establish a group of donors specifically to be called upon by the RIE, and initially managed to recruit about eighteen individuals, mostly other students. This group ran for about two years before the students graduated and moved away, resulting in dwindling numbers of donors.

From the Minutes of the Board of Management of the RIE.
[LHB1/1/64]
Both A Desmond Stoker and J.R. Copland embodied a central tenant of the donor system as we have it now. Stoker was Type 0, considered a ‘universal’ donor and able to give his blood to any recipient without adverse reaction He gave ten pints of blood before being warned by other medical professionals of the potential harm he was causing himself! Similarly, in one report of his service, Copland reported that “one organiser” (most likely Copland himself) “has given fourteen pints”. Both men were of the opinion that blood donation should be an act of charity, with blood offered and received freely. When a meeting was called in June 1936 to establish a centralised Blood Transfusion Service “in order that this important work might be carried on in future”, the question was raised of whether donors should be paid for their service. This was rejected, and the idea that donations “should be the free will offering of men who love their fellow mortals” was heartily expressed.

Publicity posters.
[GD14/14/13/2]
That is not to say, however, that this gift has gone unappreciated. The letters of thanks received by the service demonstrate the gratitude and indebtedness that both recipients and their family have felt throughout the years. As the writer of this particular letter remarks, “I know that all donors give their services for the benefit of others and without thought of thanks or reward: but I cannot help thinking that the knowledge of the recovery they have helped to bring about must be a pleasure to them”.

A letter of thanks written to a donor, in J.R. Copland's correspondence files.
[GD14/11/2]
Recognising the unique gift that donors offer has always played a crucial part in the operation of the service, as can be seen the issuing of badges to commemorate milestone donations. World Blood Donor Day gives us another opportunity to celebrate donors and their contribution to modern medicine. 

You can find out more about registering as a blood donor on the Scottish National Blood Transfusion Association website

___

Sources

Masson, A. H. B. (1985). History of the Blood Transfusion Service in Edinburgh.  


Friday, 10 June 2016

Making a grab for it…!



Collection care is a big part of our responsibility for LHSA: we work hard to ensure that our holdings are safe, but we also need to prepare in case something outside our control goes wrong. It’s easy to think it will never happen to you, but the recent Glasgow School of Art fire shows that no-one is immune to disaster, and we need to be ready to deal with any problems that may face our collections calmly and efficiently.

The last few months have seen a lot of work on the University’s Disaster Response and Recovery Plan, which also covers LHSA’s collections. Much of this work has seen new additions to the Plan itself: freshly-written sections provide suggested responses to various possible scenarios, and checklists for key members of a response team have been expanded, to name just a few improvements. It’s not all been additions to a Word document though, there’s been some hands-on activity too!

This week I helped provide a bit more practical infrastructure to our Plan, mainly to improve access to useful materials and equipment, with the assembly of grab bags for those members of staff who are most likely to lead a response effort. The grab bags are full of useful pieces of kit including protective clothing (shoes, gloves etc.) and practical equipment like torches and stationery (including a LHSA pencil!).

We produced grab bags for eight members of staff and several, smaller, bags to be kept in strategic positions in our building. The images show the staff grab bags (complete with wellies, safety shoes and hard hats) immediately below, and then the smaller grab bags in various stages of construction.





One of the bigger staff grab bags is for me, so now to find somewhere to stash it at home!

Friday, 3 June 2016

Edinburgh's medical women...

Outreach at LHSA recently has centred on the significant contribution of women to Edinburgh's medical life. In the first of two blogs on women and medical work, Louise looks at the history of the Medical Women's Federation in our region:

Last month, we were invited to take along a small archive display to the Spring Conference of the Medical Women’s Federation (MWF) in Edinburgh. MWF developed from the Association of Medical Women, a group of nine female physicians set up in 1879, which in fact comprised most qualified women at that time. As provincial associations were set up, it became clear that a Federation was needed to represent both female doctors and their patients, particularly following prejudices against qualified women who had offered their services during the First World War. Articles of Association for MWF were drawn up in 1917.

The archive of the Scottish Eastern Association (SEA) of the MWF was donated to LHSA in 2012 and has been recently catalogued. As we near the 2017 centenary of MWF’s foundation, our display reflected how the Federation functioned at a local level in a historic medical city: from interaction with clinical debates, to supporting doctors in education and practice, forming social and professional communities, and fighting for workplace equality for female physicians.

The concerns of the national Federation through the years are reflected by the SEA archive at a local level, including contributions to often-controversial debates affecting women’s health, such as birth control. This is the first page of the earliest SEA committee minutes that we have, from 1928. MWF’s active roles in women’s health and education are reflected here, from arranging teaching on birth control practices to organising study groups to mark the centenary of prominent health and social reformer Josephine Butler (1828 - 1906). Butler was primarily known for her campaign against the Contagious Diseases Acts, which permitted forced examination of sex workers in an attempt to control venereal disease:

Scottish Eastern Association Committee Meeting, 13 February 1928 (GD51/1/1/1)
Issues around equal pay and opportunity are also strongly represented in SEA papers, along with members’ leading role in campaigns around staffing in, and against the closure of, Edinburgh’s two women’s hospitals (Bruntsfield Hospital and Elsie Inglis Memorial Maternity Hospital). For example, MWF campaigned against the ‘marriage bar’ in the 1930s, which required the resignation of working women upon marriage:

Central MWF position on the ‘marriage bar’, 1934 (GD51/1/2/1)
Campaigns for equality and opportunity went on into the second half of the twentieth century. In 1972, a ‘retainer scheme’ was introduced for female doctors who could not work a full-time week due to family commitments. Professional subscriptions were subsidised by the scheme, in return for a commitment from participants to keep abreast of current practice with continual professional development. From 1976, the SEA supported women on the Retainer Scheme attending morning medical lectures with a crèche staffed by volunteers:

Programmes for morning lectures for doctors on the 'Retainer Scheme', supported by MWF creche, 1990s (GD51/8/1)
However, it wasn’t all work and no play for MWF members. One thing that really stands out from the SEA archive is that members were so organised that even their social events were recorded and archived in detail! This is one of the most popular items from the display - an invitation to a party with a rather strange blend of entertainment:
Invitation to 'At Home' for female medical students, 1932 (GD51/1/2/1).
We also brought along some material from our women’s hospitals collections to the display, bringing home the connections between MWF and the women who were instrumental in shaping hospital care in our region, such as Gertrude Herzfeld, the first practising female surgeon in Scotland:

Gertrude Herzfeld in 1924 at Bruntsfield Hospital. She was a member of the SEA from 1920s and served nationally as MWF President from 1948 to 1950 (LHB8/17/1).



Friday, 27 May 2016

Clubbed fingers, long eyelashes, and a subaverage condition: unusual markers of tuberculosis in the Royal Victoria Dispensary case notes


This week, Rebecca takes a look at the Royal Victoria Dispensary case notes, exploring the wealth of information collected from each patient before they were clinically examined.

Diagram of the Edinburgh Scheme, showing the central role of the dispensary.
(LHSA Slide Collection)
 
I’m currently working on a series of case notes from the Royal Victoria Dispensary, the outpatient clinic which acted as the first point of contact for people suspected of having tuberculosis in Edinburgh. The dispensary, based on Spittal Street with an additional clinic in Leith, saw thousands of people each year.

The former dispensary on Spittal Street, Edinburgh
(screenshot from Google Street View ©2014 Google)
Being referred to the dispensary was not a sign that someone had tuberculosis, rather it was a way for likely cases to be examined and a diagnosis of tuberculosis eliminated. Patients would be referred for a number of reasons: they may have lived with or been related to a notified case of tuberculosis; their GP or School Medical Officer may have referred them based on their symptoms; they may have been sent for a ‘large film’, a more detailed X-ray to check on any abnormalities detected during mass radiography; or they might require examination before entering certain professions. For example, all apprentices in the printing trade would be screened, as it was an industry with a high mortality rate from tuberculosis, attributed to crowded working conditions. Others requested to go in for an ‘overhaul’, usually due to nervousness that they had the condition.

When they arrived, the patient would be quizzed on a variety of factors which would give a general background to their health and lifestyle. But what exactly was it that was being looked for?

Case note, for a symptomless contact of TB, showing the standard checks performed at the RVD
(LHB41 CC/2/PR2.5695)

Firstly, a patient would be questioned on the presence of key symptoms including coughs and sputum, dyspnoea (breathlessness), and haemoptysis (coughing up blood). Temperature, pulse, and weight gain or loss would also be recorded - not for nothing was TB also known as ‘consumption’, as dramatic weight loss would often accompany the condition. Other symptoms such as night sweats or the presence of finger clubbing, associated with severe pulmonary tuberculosis, would also be recorded.

Pulmonary tuberculosis can often be present without visible symptoms, so factors such as the size of the patients’ family and any family history of tuberculosis were also recorded. Tuberculosis spreads following prolonged close proximity to sufferers, so a close relationship with a sufferer was worth investigating. The patient’s occupation would also be noted, in order to ascertain if they worked in a dusty occupation or a physically taxing position. This information was also a valuable indicator of poverty and poor living conditions, which were associated with tuberculosis and which a doctor would have borne in mind when recommending treatments.

Case note from 1949, includes a record of the smoking habits of the patient -
note that this is not pre-printed on the form.
(LHB41 CC/2/PR2.5704)

From the 1940s onwards, case notes also note how many cigarettes a patient smoked per day, which is interesting considering the relationship between smoking and lung cancer was first proposed, and not immediately accepted, around 1950. Smokers who were found to have some lung symptoms were usually told to stop or curtail their smoking, which goes against the impression that many people now have of the popular and clinical attitudes towards tobacco consumption at the time.
A final note on the patient’s general condition (‘subaverage’, ‘satisfactory’, etc.) would also be made. A few case notes refer to ‘long eyelashes’, referring to an earlier idea of two forms of tuberculous patient; the beautiful, delicate consumptive, with long eyelashes and fair complexion, and the other with “coarse, thick features” and a sallow complexion. If a patient was perceived to live in poor conditions, to be malnourished, or to have an unsatisfactory personality, this would often be recorded as well.

Note on a patient's general condition: "GC Fair only. but not bad for age"
(LHB41 CC/2/PR2.5717)
All of this information would be recorded before a patient even got so far as a clinical examination or an X-ray, and it is not clear from the case notes if this part of the examination was carried out by a doctor or not. But it was important for all of this to be recorded, and it is obvious from the case notes that this information was a useful aide in determining if a patient was suffering from pulmonary tuberculosis. As well as this, these case notes also provide a fascinating insight into the work and habits of tens of thousands of Edinburgh residents in the post-war period.


Sources:
LHB41 CC/2/PR2

Cairns, Margaret; Stewart, Alice, ‘Pulmonary Tuberculosis Mortality in the Printing and Shoe-making Trades. Historical Survey, 1881-1931.’, Brit. J. Preventive & Social Med., 5 (2), (Apr 1951), pp. 73-82 http://www.cabdirect.org/abstracts/19512703370.html;jsessionid=53F6E61EACAA51F66F6650F988C4EE89?freeview=true

Imray, Keith, A popular cyclopedia of modern domestic medicine : comprising every recent improvement in medical knowledge : with a plain account of the medicines in common use, (1849), available at: https://archive.org/stream/63580420R.nlm.nih.gov/63580420R
Macfarlane JT, Ibrahim M, Tor-Agbidye S., ‘The importance of finger clubbing in pulmonary tuberculosis.’, Tubercle, 60 (1), (Mar 1979), pp. 45-48.

Ruddock, E. H., The diseases of infants and children and their homœopathic and general treatment, (1899), available at  https://archive.org/details/b28134825

Woodcock, H de Carle, ‘Adolescent and other forms of tubercle’, Tubercle¸5, 2, Nov 1923, pp.64-69 http://www.sciencedirect.com/science/article/pii/S0041387923800939
‘Smoking and cancer of the lung: minister’s press release and statement in House of Commons’, Tubercle, 35, 3, (Mar 1954), pp.70-72) http://www.sciencedirect.com/science/article/pii/S004138795480047X

Friday, 20 May 2016

An example of obsolete treatment in the Norman Dott Case Notes (1920-1960): lobotomy.

     The Norman Dott case notes are an invaluable source for the history of neurosurgery. They contain many examples of pioneering medical techniques, but also of treatments and diagnoses which are now obsolete. One of the most striking examples is the psychosurgical procedure on the frontal lobe better known under the name ‘lobotomy’. Nowadays, this word evokes a botched, barbaric practice that trampled the rights of patients and stripped them of their individual and humane qualities. However in the 40s and 50s, this operation was regarded as a way to relieve some patients of their sufferings when all the other treatments had failed.

     In Britain, where the term ‘leucotomy’ was used rather than the American word ‘lobotomy’, the first operations were carried out at the Burden Neurological Institute in Bristol in 1940, at the instigation of Frederick Golla, Effie Hutton and F. Wilfred Willway. The use of the procedure peaked in the late 1940s and early 1950s, with nearly 1500 operations a year. However, the poor results of the operation, the harmful consequences observed in patients, and the progressive introduction of psychiatric drugs led to a sharp decline of the practice by the end of the 1950s. The vast majority of the case notes I have been working on as the cataloguing archivist of the Norman Dott project date from this period; and indeed, out of the 2500 case notes I have catalogued so far, less than twenty mention a leucotomy. However, these cases greatly help to understand in what context it was used and on what kind of patient, and for which results.

     The vast majority of patients who underwent a leucotomy in the Norman Dott case notes at the end of the 1950s were women, aged from 24 to 73 years old. They were usually suffering from various mental illnesses described in the case notes as: ‘hebephrenic schizophrenia’, ‘catatonic schizophrenia’, ‘chronic depression’, ‘agitated depression’; or more precisely: ‘long-standing and deep seated neurotic illness in an inadequate personality’, ‘recurrent depression with maniac depressive personality’.

     Doctors were well aware that leucotomies were not a ‘miracle solution’, far from it. They knew that recovery was not guaranteed and that it could change the patient’s personality and make them less socially apt; however the alternative was judged worse and the goal was to dull the symptoms of psychiatric illness to enable the patient to lead a more peaceful life or at least to make him or her easier to nurse. This sentiment is expressed by two doctors considering a leucotomy at the Royal Infirmary for their patients: ‘I think that leucotomy would relieve his suffering and might make it possible for him to make some sort of adjustment outside hospital’; ‘[I feel] that a leucotomy would allow of a modified social recovery enabling [the patient] to lead a fairly normal life though leaving her rather ineffectual and needing guidance in her day to day activities’.

 
Excerpt from a case note relating to a female patient suffering from chronic depression, 1959. LHB1 CC24 PR2.20898.

     One must keep in mind that the procedure was only used as a last resort. The patient had to be in a deeply disturbed state which would make living in these conditions unbearable. Again quoting from Norman Dott case notes, it is said that one patient ‘was inaccessible and auditorily hallucinated. There was considerable volitional retardation and she was monosyllabic’. For another patient, ‘operation was especially commended because of intractable noisy perseveration; the word “money” occurring endlessly’. Moreover, leucotomies were only performed when all other treatments had failed: in the case note PR2.20920, it is said that ‘ECT has only produced temporary improvement and tranquillizers have not been effective’, in the case note PR2.20698, the doctors who examined the patient agreed that ‘he should have a leucotomy carried out in view of the prolonged period of unsuccessful conservative treatment’. At the time, other treatments included electroconvulsive therapy (ECT), tranquilizers, and modified insulin injections, also known as insulin coma therapy (ICT).

The following extract from a case note describes a leucotomy performed in 1959 on a patient suffering from ‘agitated depression’ at Ward 20 of the Royal Infirmary of Edinburgh. Essentially, the surgeon would drill a pair of burr holes into the skull in order to insert a sharp instrument called a leucotome into the brain, that he would then sweep from side to side to separate the frontal lobes from the rest of the brain.

Operation notes describing a leucotomy, 1959. LHB1 CC24 PR2.20920

     From what we can gather, the outcomes of the leucotomies carried out in the Norman Dott case notes were very mixed. Only one patient seemed to do better: ‘in the few days after the operation and prior to her return to Bangour, [the patient] certainly appeared more relaxed, approachable and less disinclined to talk’. However most of the time the results were more disappointing: ‘little change was noted after operation’; ‘however, [in the following days], there was some suggestion of her being less accessible’; ‘in the first post-operative days [the patient] was confused and towards the end of the first week still disorientated in time; somnolent and incontinent of urine and faeces. He recognised his surroundings; knew that he had been operated on and why. There was no appreciable change in his mood’ and he ‘still appear[ed] to be grossly preoccupied and depressed’. Unfortunately, the case notes only mention the days immediately following the operation so we have no way of knowing how the situation evolved for these patients on the long term, but from other leucotomy cases, we know that it was not uncommon for patients to be crippled for life or to live in a vegetative state.

     The use of leucotomy has been criticized from the very beginning for the risks it posed for the patients and for its very limited and often unpredictable results, although it was performed in situations in which the doctors thought that the benefits would outweigh the risks. The cases we find in the Norman Dott collection, although few in number, enable us to understand the context of this operation, and what the reasoning behind its use was. The study of medical failures and outdated treatments is essential to understand the evolution of neurosurgery.

Sources:

History of psychosurgery in the United Kingdom [online]. Wikipedia. Available from: https://en.wikipedia.org/wiki/History_of_psychosurgery_in_the_United_Kingdom [Accessed 19/05/2016].

Levinson, H. (2011), The strange and curious history of lobotomy [online]. BBC News magazine. Available from: http://www.bbc.co.uk/news/magazine-15629160 [Accessed 19/05/2016].