November 2014 - Page 2 of 2 - Northumberland Archives

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

Primary Infection

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

Secondary Infection

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

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

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

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

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

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

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

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

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

Stannington Sanatorium

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

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

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

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

Sources

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

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

The Stannington Sanatorium Project has been generously funded by the Wellcome Trust, a charitable foundation designed to aid research into, amongst others, Medical Humanities to explore the social and historical aspects of scientific and medical practices.

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

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

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

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

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

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

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

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

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

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

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

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

Types of Tuberculosis at Stannington Sanatorium

Sir Henry Wellcome