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World Tuberculosis Day 2016!

09/07/201624/03/2016 by Northumberland Archives

In honour of World Tuberculosis Day, we have a guest blog from Rebecca Cessford. Rebecca is a PhD researcher with the AHRC funded Heritage Consortium based at the Universities of Hull and Bradford. She will be using the Stannington Sanatorium Collection to study tuberculosis in the past using the archaeology of human remains and medical history. Here she tells us about her research and the role of the Stannington Collection in it.

When we think of tuberculosis (TB), images are conjured of a romantic disease causing a bloody cough, a pale complexion and weight-loss, the romanticised disease of the 19^th century. What we do not think of is TB roaming the streets today. But tuberculosis is still a great threat, with over a million people dying of the disease each year and over 6,500 new cases declared in the UK during 2014. With increasing multidrug resistant strains of tuberculosis, is it possible to look back at a time before antibiotic drug therapy to better understand the future of this global emergency?

Early Discovery, Early Recovery 1929. Image from the National Library of Medicine, USA

Tuberculosis is a disease that extends as far back as the Neolithic period in Europe, with the earliest case reported in England coming from Dorset dating to the Iron Age. However, our ability to identify tuberculosis in skeletal remains from archaeological contexts is difficult. Firstly, tuberculosis of the bones and joints only affects 3-5% of all cases. Secondly, bone can only react to disease in a limited number of ways with many diseases causing similar bony destruction and remodelling. There are also problems identifying tuberculosis in the remains of children, due mainly to the under-representation of children in the archaeological record.

The most characteristic feature of tuberculosis in the skeleton is Pott’s Spine, an angular deformity in the mid to lower spinal column caused by the collapse of one or more vertebral bodies. The presence of this deformity has, for many years, been the only way of diagnosing tuberculosis in human remains with any certainty, despite the fact that any bone in the body can be affected. Advances in ancient DNA and biomolecular studies in archaeology mean tuberculosis can be tested for, even in the absence of any physical pathologies. However, these destructive and costly procedures are not without their limitations, still leaving much reliance on routine macroscopic observations (seen with the naked eye) of dry bone remains.

Pott's Spine the main diagnostic feature of tuberculosis in skeletal remains. Image courtesy of https://www.dur.ac.uk/images/archaeology/researchprojects/Roberts_TB.jpg — Pott’s Spine – characteristic collapse of the vertebral bodies causing an angular deformity of the spine due to tuberculosis. Image from University of Durham.

My research aims to look at the potential for using pre-antibiotic clinical radiographs (x- rays) as an aid to the macroscopic identification of tuberculosis in human remains, focussing specifically on infants and children. To do this, I intend to undertake a thorough examination of all the radiographs demonstrating skeletal tuberculosis to look at variations in progression of disease over time; the outcomes of healing on bones and the distribution of tuberculosis across the body where more than one bone was involved. In addition to this I will look at the corresponding medical file for each set of radiographs drawing on details outlined in the medical notes and x-ray reports to add to my own observations from the radiographs for an informed review of the underlying processes to bone and soft tissue being observed. It is hoped that the compilation of this data will provide a more detailed understanding of the processes involved in advancing tuberculous infection with comparative examples from pre-antibiotic radiographs. This strives to increase the ability to diagnose tuberculosis in archaeological remains even in the absence of Pott’s Spine.

Tuberculosis of the Knee: HOSP-STAN-07-01-02-91_09

Tuberculosis of the Spine - HOSP-STAN-07-01-02-1662-22 — Tuberculosis of the Spine – HOSP-STAN-07-01-02-1662-22

Tuberculosis affecting the finger bones: HOSP-STAN-07-01-02-641_07

By studying the patterns of tuberculosis in the past we are better informed when it comes to dealing with the disease in the present and in the future. To be able to offer an evidence-based and informed approach to tackling tuberculosis we need better criteria for diagnosing it macroscopically in archaeological human remains, to get a more encompassing view of the various manifestations associated with it. The outcomes of my research will aim to act as an aid to the identification and study of tuberculosis in children in relation to archaeological remains further identifying the worth of pre-antibiotic medical records.

The Stannington Collection is a unique resource for studying this long standing infectious disease in children from the early to mid-20^th century, many of which are still alive today living with the memories and/or side effects of the disease. I would also like to take this opportunity to thank the former patients of Stannington Sanatorium who expressed support for academic research to be undertaken on the collection during the first phase of the Stannington Sanatorium Project; their support makes research all the more worthwhile.

Digitising the Stannington Sanatorium patient files

21/12/202010/03/2016 by Northumberland Archives

As the Stannington Sanatorium Digitisation Assistant I am responsible for digitising over 4,000 patient case files and their contents, redacting personal identifiable information from these and uploading digital copies of the core documents to our publicly accessible, searchable, online catalogue. Before I can do this, my colleague, the Project Assistant has already sorted the forms, charts and various other items contained in each file into core and non-core documents and repackaged them in acid free folders for long term preservation. You can read more about this here.

A file ready to be digitised — The documents of patient file HOSP-STAN 07/01/01/2261 prior to digitisation

Before being digitised the pages in each file are checked to make sure they are in the correct order and any dog eared corners or folds are straightened out. The pages in the folder are then photographed on both the front and reverse sides to make sure that all the information in each folder is captured. The number of images captured varies from file to file and can be from just a few up to around fifty. Most files have around 10 to 15 pages, but the largest digitised to date contains over 140 pages!

We digitise the files using a high specification digital SLR camera connected to a computer. This allows us to take high resolution photographs of each page and is much quicker than digitising each page separately on a flatbed scanner. Using a flatbed would be the normal approach however the time constraints on the project mean we are digitising over 1,500 pages every week so this approach isn’t feasible.

Camera stand and laptop — The camera stand and laptop used to digitise each file.

The images are then processed and saved to nationally recognised standards set by The National Archives. Each file is saved in Tiff and Jpeg formats. The Tiff format creates files of a large size, but ensures that all the original information from the photograph is retained. Because of this and the sensitive nature of information in the un-redacted files they are stored on DVD in the Northumberland Archives strong rooms for security and long term preservation. The smaller Jpeg format allows us to keep these digital files on our own servers and readily accessible to staff and researchers if required.
The core documents from each folder (cover, case notes, x-ray card and discharge report) then have any information which could identify patients or is considered sensitive removed. This process involves using photo editing software on a computer, and reading each page to check for information such as names, addresses and dates of birth, and redacting it. This is a time consuming process not made easier by having to read a lot of hand written doctors’ notes!

Core documents being redacted in Adobe Photoshop — Adobe Photoshop is used to redact sensitive information from the core documents.

The final stage of the process is to upload the images to the relevant records on our online catalogue. Once this has been done a selection of pages from each file are publicly viewable along with each file’s catalogue entry and the digitisation process is complete. Currently over 18,000 pages have been digitised from over 1,400 patient files. Over 6,000 core documents are already viewable online via our catalogue in addition to a large number of radiographs and early patient files which were digitised during the first phase of the project.
A typical set of core documents from the file of a patient suffering from tuberculosis admitted to Stannington Sanatorium in the early 1950s can be seen below.

The front cover of a file — HOSP-STAN 07/01/01/2261/01

Inside the cover of a patient file — HOSP-STAN 07/01/01/2261/02

HOSP-STAN 07/01/01/2261/07 - — HOSP-STAN 07/01/01/2261/03

Pages from a patient file incuding discharge report — HOSP-STAN 07/01/01/2261/07

Working as the Stannington Sanatorium Project Assistant

21/12/202017/02/2016 by Northumberland Archives

As the Stannington Sanatorium Project Assistant my responsibility is to ensure the good preservation and access to the Stannington Sanatorium records. Since early November I have been removing boxes of our patient files from the shelves and repackaging them. This follows a set process. First I begin by opening the file and separating out the core documents from the other contents of the file, and securing them to the inside of the file with an archival quality brass paper clip. The core documents include X-ray records, discharge reports, treatment notes and case notes. These contain a wealth of information about each patient’s treatment and health during their time at the Sanatorium. The non-core documents vary greatly in content, usually (but not always) including temperature charts, a history of illness and medical permissions form completed by parents, reports and letters of their transfer. There are often a number of other documents included, and

A repackaged file with supplies - unfolded card folder, archival tape, Brass paper clips and a bone folder for folding the flaps of the folders. — A repackaged file with supplies – unfolded card folder, archival tape, Brass paper clips and a bone folder for folding the flaps of the folders.

we will look more closely at the contents of the files in a future blog. I also ensure the file itself is in good order for its conservation, that there is no yellowing sticky tape, old paper clips or pins that may corrode.

It is then folded with an archival-grade four-flapped envelope, which we were able to purchase thanks to our Wellcome Trust grant. These are high-quality, acid-free card envelopes; an excellent way to protect the documents from damage and dust ingress. This is then given a printed label with the file’s reference number, and tied together in acid-free archival tape tied with a quick-release knot. Due to the thickness of the files after their repackaging additional boxes are required, and I estimate repackaging will at least double the number of boxes the collection occupies.

Files yet to be repackaged on their temporary shelving

This all has to be given extra space within the Northumberland Archives strongrooms. I have moved the boxes yet to be repackaged to a new temporary location, and am refilling the shelves as the boxes are completed, updating their location references as I go. I have just passed the halfway mark, but there is a lot still to be done!

Once completed however, the records don’t just sit unused. We often have Subject Access Enquiries, usually made by former Stannington patients wishing to see their records, and these are dealt with by our research team. We require authentication and permission to do this, which can take some time. The documents are not only useful for finding out more about individual lives, but for research into tuberculosis in children and the history of its treatment. A number of research institutions have looked at redacted images of the files and radiographs, to learn more about Tuberculosis.

Repackaged boxes of files at their new permanent location

This has to be done with the strictest patient confidentiality, and we will discuss more about the redaction process in future blogs. A former colleague at the Northumberland Archives, Becky Cessford, is looking at the uses of the Stannington Sanatorium collection in the wider fields of archaeology of human remains, history of medicine and archival outreach in her PhD. She will discuss her fascinating project in a blog post for us sometime soon. It is fantastic that the records are being used by former patients and researchers as such a valuable collection should be appreciated. The team last year started to raise the collection’s profile through these blogs, talks, an online exhibition and a touring exhibition, and I hope to be able to carry on some of this in phase two. You can see the online exhibition here, and the touring exhibition will soon be moving from libraries across Northumberland to HM Prison Acklington until late March.

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