Sea air and tuberculosis (TB beside the seaside)

Today we have a guest post written by one of our project volunteers, George Cooban.

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It’s the time of year when lots of us go to the seaside. The case files tell us that many of the children in the care of The Children’s Society in the late-19th and early-20th centuries also visited the coast. But, unlike today, it was often for medical reasons, rather than a holiday.

Previous posts on this blog have highlighted cases where various health conditions led to children spending time by the sea. The coastal convalescent homes run by The Children’s Society at Hurstpierpoint and Broadstairs, established to facilitate the care of sick children sent there, have also been researched in detail. However, I was keen to find out what the case files can tell us about the thinking behind this formerly commonplace practice.

Photograph of matron, staff and children outside 'Coronation Cottage', St David's Home, Broadstairs, Kent, c1912

Tuberculosis features very prominently in the case files, and the medical rationale behind the way it was dealt with is often quite clearly recorded. Therefore I decided to focus on cases relating to this condition in this blog post.

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One thing we notice when examining many of these case files is that seaside convalescent homes were viewed as a means of preventing tuberculosis. (So not all the children who stayed at them were, strictly speaking, convalescent). This is illustrated by reports such as this one, dated 19 June 1910.

“There is a delicate girl aged 13, May [surname], who has been [at the Leamington Home for Girls] for many years, but has to be sent annually to the sea for her health. She probably has a tendency to tuberculosis, but no disease has developed owing to care. She now looks well having just returned from the sea. As she is now at a critical growing and developing age, it would be desirable to move her if possible to Felixstowe before winter for the next two or three years before she goes out. Leamington is relaxing and she needs bracing sea air.”

Another case file contains a medical certificate, written on 7 June 1905, which states that a child, a seven year old girl named Dorothy, has “a tendency towards consumption [tuberculosis]” and recommends moving her to the coast. Later correspondence says that she was treated with a special diet including new laid eggs.

Terms like “delicate” and “a tendency to tuberculosis” appear regularly in the case files. The health of the children referred to in this way was not good, but there is evidence to suggest that sending them to the seaside was seen as a preventative measure, stopping the development of more serious problems.

Several case files, such as those quoted above, give the impression that “sea air” was seen as healthy. But a letter from another case file provides a bit more detail. Dated 3 December 1913, it reports on the condition of a 13 year old girl, Annie, who was staying at St. David’s convalescent home in Broadstairs, Kent:

Letter reporting on the condition of Annie, who was staying at St. David’s convalescent home in Broadstairs, Kent, 3 December 1913 (Case number 13819)

Dec. 3rd. 1913.

Dear Sir – I am sorry to
inform you that
Annie [Surname]
has been examined by the
doctor today & he asks me
to write at once to you so
that she may be removed
to a sanitorium [sic] as early
as possible.

Owing to high winds & rain
I was obliged to remove her
bed indoors a fortnight
ago, & since then she has
gone down rapidly &

Dr. Brightman considers
it unsafe for her to be
in a room with other children
owing to her Tubercular
condition.

We have no proper place
for out of door patients
in the winter.

I am very sorry indeed
she is such a nice, willing
& gentle child.

Yours faithfully
Elsie Philip-Smith

The most surprising thing about this letter is the time of year it was written. It is implied that the only suitable place to treat tuberculosis patients is outdoors, even in winter. Open-air treatment for conditions including tuberculosis was fairly common a century ago. By arranging beds out in the open, as can be seen in the picture from The Children’s Society’s St Martin’s Home in Pyrford below, patients would be exposed to lots of air.

The open-air ward at St Martin’s Home, Pyrford, Surrey, 1928

From the letter about Annie we discover that open-air treatment was practiced all year-round. The need for weather which allowed it to take place is also evident. It can be said, in fact, that the weather conditions were of greater importance than how close the patients were to the sea. This is certainly suggested by a letter from another case file. A doctor writing in 1909 advises that a girl “threatened with phthisis [tuberculosis]… would be much benefited by removal to a warmer & more equable climate in the South of England.” Since the girl was living at that time in the St Barnabas’ Home For Girls, New Brighton, Cheshire – a place right by the sea – we can say that sea air on its own was not seen as especially important for health.

The prioritisation of fresh air, together with an “equable climate”, features in medical writing from the time. An article in the British Medical Journal from July 1898, for example, advises that an open-air sanatorium for tuberculosis sufferers should be situated “where the prevailing breezes sweep over the sea, or over moorland, or, better still, where these two conditions are associated, and fresh, pure air comes from all quarters of the compass.”

Similar thinking appears in another case file. A doctor’s report from 1927 on a 16 year old boy, Leslie, who had been working at The Children’s Society’s head office in London, states that he is “obviously predisposed to tuberculosis, especially as he works in London”, and recommends for him “an outdoor occupation, preferably in the country or at sea, as this will probably prevent any active tuberculosis developing”. The Society helped Leslie find work as a steward on the SS Baltic. This was quite different to the career previously envisaged for him: earlier correspondence highlights Leslie’s aptitude for draughtsmanship.

This case, like the others, shows the impact contemporary medical opinion had on the lives of children who had tuberculosis or were at risk of contracting it. Nowadays the condition can be treated with antibiotics. But a century ago the dangers were much greater, and the response was often to move children long distances for the good of their health, even if they were only considered susceptible to tuberculosis.

At a time when urban air pollution in Britain was severe, sea air was valued for its quality. However, simply being by the coast was not essential: the objective was fresh air. But the convalescent homes established on the coast did offer other benefits besides sea air. The staff were better trained to look after children with health problems. There were opportunities for the children to get exercise, which may have been limited in more urban homes. There is also evidence in some case files that children were given more or better food to build them up while they were staying in the convalescent homes. Finally, a modern study has suggested that there may be health benefits to be gained from living on the coast, but they are psychological ones, and not related to the air there. The case files show that, in the absence of today’s more effective treatments, a proactive approach to tuberculosis was taken, and this surely saved many lives.

Want to find out more?
Click here to read another blog post on sea air and health, featuring a case where the avoidance of sea air was recommended.

Historic articles from the British Medical Journal discussing open-air treatment of tubercular cases can be found here: http://www.bmj.com/archive

Tuberculosis in the bones

Today’s case highlights a condition that was fairly common in the late-19th and early-20th centuries, although it’s not very well known today: tuberculosis, but not as you might expect.

It’s easy to think of tuberculosis as purely a lung disease, but in some cases the infection can affect other areas of the body instead. Children’s files in the archive give us examples of tuberculosis in the digestive system, the nervous system, and scrofula (being tuberculosis in the lymph glands in the neck). One of the most common tubercular diseases we’ve found, after tuberculosis in the lungs, is tuberculosis affecting the bones and joints. Often this type of infection occurred after an injury or breakage, with tuberculosis developing in the damaged bone.

Grace was living in Dinas Home For Girls in Brecon, Powys (then in Brecknockshire), when it was taken over by The Children’s Society (then known as the Waifs and Strays Society) in 1909. At this time, Grace would have been 12 years old. She was from London and had entered Dinas home through another charity, the Fulham branch of the Rescue Society, after her parents had separated. Her father had been described as “very unsteady”, with Grace and her three siblings having been neglected when under his care.

While in the Dinas Home, an abscess was found on Grace’s hand, which was identified as being the result of tuberculosis. In early 1911, with Grace around the age of 13, she had an operation to remove the abscess and was then sent to the coast for a month to recuperate. Unfortunately, the operation wasn’t as successful as had been hoped; by December another abscess had appeared on Grace’s wrist.

Grace was seen by a doctor, who recommended that her hand should be bandaged up and that she should be given complete rest and sea air. Because of this recommendation, Grace was sent to The Children’s Society’s new convalescent home, St David’s Home in Broadstairs, Kent.

In St David’s Home, Grace could receive the medical care she needed. Her hand and wrist were treated with poultices and with boracic lotion, which was an antiseptic. Grace was also found to be suffering from head lice, which was treated with sassafras. These treatments seemed to be successful and, in time, the abscess started to clear up and the swelling on Grace’s wrist went down.

After three months in St David’s Home, Grace was transferred to St Audrey’s Home in Bedford. When she arrived at St Audrey’s Home, it was found that Grace was not able to use her hands much. The healed abscess on her right wrist had left it swollen and weak, while the doctor at the home found that she also had a “poisoned” finger on her left hand. After enquiries it was found that just before Grace had left St David’s Home she had pinched her finger in an accident. It was thought that underlying tuberculosis might have caused Grace’s injured finger to go bad.

As it had been discovered that Grace was still suffering from tuberculosis, she quickly returned to St David’s Home in Broadstairs for further treatment.

By September 1912, having been in St David’s Home for a further four months, Grace was described as having put on weight and being in good health. She was now 15 years old and it was thought best to send her to a home where she could start to learn a trade to allow her to go to work when she was well enough.

In October, Grace was sent to St Barnabas’ Home in Newark, Lincolnshire. She didn’t remain in this home for long, however. By January the next year, the doctor at the home had sent on a medical certificate saying that Grace was still suffering from tuberculosis in her wrist, with the disease now in an active state.

And so, in March 1913, Grace was sent to St Anne’s Home in Clapham Park, London, where she could be examined by a doctor. The result of this visit can be seen in the letter below:

Letter from case file 14799, mentioning Grace's visit to a doctor in Harley Street followed by an x-ray at Charing Cross Hospital, 1913

March 28th. 1913

Re Grace [surname]

I took this girl today
to Mr. Boyd, 134 Harley St W, to meet Dr.
Rose Turner there for an interview. Dr. Boyd
sent us to X Ray Dept. Charing X
They gave me no messages (although we
waited for the same) as to when to go
there again, nor whether she was
to be made an in-patient at that
Hospital.

E A Bailey
Travelling Matron W. & S. Society

Dr. Turner has case in
hand. 29.3.13

The x-ray must have shown signs of tuberculosis because it wasn’t long before Grace returned to Charing Cross Hospital to have an operation on her wrist. After this she would need extra medical care while recuperating, but the active condition of the tuberculosis meant that she couldn’t return to St David’s Convalescent Home in Broadstairs where the children there, already ill, might be put at further risk of infection.

Instead, in April 1913, Grace was transferred to the Westminster Union Infirmary in Lincoln’s Inn Fields, London and then to the Strand Union Infirmary in Edmonton, London. Here it is said that Grace was staying in a small ward and that “… the Doctor has ordered her special diet, extra milk &c [etcetera]”. When visited by one of The Children’s Society’s travelling matrons, Grace was found to be doing well, with her wrist weak but healed up.

This is all we hear about Grace until November 1913. By this point we find that she had been transferred to the Isolation Hospital in Ramsgate, Kent, but there are no updates as to her condition. With no further correspondence in Grace’s file, we can only guess at how she was doing. The operation on her wrist may perhaps have healed, but the fact that she was still in hospital suggests that her tuberculosis hadn’t cleared up completely and was potentially still active. The prognosis for Grace, then, didn’t look good, and without the option of the antibiotics we have today, it seems like further surgery may have been Grace’s only hope.

As sad as it is, Grace’s file gives us some interesting information about medical treatments in the early-20th Century. We find out that boracic lotion was used as an antiseptic and that sassafras was used to treat head lice. Not to mention, we have evidence of x-rays being used as a tool for diagnosis, and this only 18 years after x-rays had first been discovered.

Most importantly, Grace’s file shows us what it would have been like to live with a tubercular infection in the joints and bones. This was a disabling condition that left Grace living in convalescent homes and hospitals, unable to continue the training she had started. Even invasive surgical treatment, it seems, wasn’t able to stop the infection fully, leaving potential for the disease to return and spread to other parts of the body.

(For more information about the early use of x-rays, see this page from the British Library.)

Caring for a child with scrofula

James was an orphan. He was born in Oxford in 1886 where his father worked as a guard on the railway. James would have been about two years old when his father died from heart disease.

After the death of James’ father, James’ mother found work as a nurse for a family living in East Grinstead in Sussex. Then, when James was about seven years old, James’ mother moved the family to Westminster in London where she started keeping a lodging house.

Unfortunately, two years later in 1895 when James’ was only nine years old, his mother died of bronchitis and pneumonia during a cold winter, leaving James and his brothers and sister as orphans.

James was the youngest of his siblings. His eldest brother, aged 25, was a soldier serving in India, while his three other brothers, aged 21 to 16, worked in Westminster; one as a road sweeper, one as a clerk and the other as an errand boy. Meanwhile James’ sister, aged 12, was adopted by their aunt.

Neither James’ elder brothers in Westminster nor James’ aunt, who also paid money to help his grandmother, were able to look after James. Temporarily, therefore, James was taken into a home for working boys, St Matthew’s Home in Westminster, which was also looking after his 16 year-old brother, Robert.

St Matthew’s Home wasn’t run by The Children’s Society (then known as the Waifs and Strays Society). It was a home for older boys, like Robert, who were working. At only nine years old, James was too young to stay in this home, and so an application was made for him to be taken into the care of the Waifs and Strays Society.

In May 1895, two months after his mother’s death, James entered The Society’s Talbot Home for Boys in Bournemouth.

Three years later in 1898 when James was aged 11 and still living in the Talbot Home, a medical certificate was filled out for him. This stated that he had a tendency to scrofula.

There had been no mention of scrofula in a previous medical certificate for James, which had been completed when he first entered the Talbot Home, so perhaps James had recently contracted the disease or perhaps the symptoms had only just started to show. Scrofula is an infection of the lymph nodes in the neck which leaves them swollen; it is sometimes caused by tuberculous bacteria, but can also be caused by other types of bacteria instead.

James remained in the Talbot Home until he was 12 years old. The Talbot Home looked after younger boys, and when they reached the age of 12 the boys often left the home to start apprenticeships in Bournemouth. It was considered that James wouldn’t do well in an apprenticeship and so instead, in 1898, he was moved to Standon Farm Home for Boys in Staffordshire. This home usually looked after boys until they were 14 years of age and trained them for farm work.

The next we hear of James is five months later in 1899 when James would have been 13. He was examined by the doctor who worked as the medical officer for the Standon Farm Home; the doctor’s report is below.

Medical report from case file 4772, stating that the child is suffering from ‘Tubercular disease of the glands of his neck’, 1899

April 4. 1899.

Jas. [surname].

This boy I have examined carefully
& I do not consider him to be a fit
inmate of this institution. He is suffering
from Tubercular disease of the glands
of his neck, of some duration, one of
which has ended in suppuration.
I should advise his removal from
this home as I do not consider the
climate here suitable to the case.
It is quite possible that the Tubercular
disease may spread to the lungs.

Thomas Dixon.
M.R.C.S. Eng.
L.R.C.P. Lond.

Reading the report, we see that James’ scrofula was tubercular and that one of the swellings on his neck had become suppurative (meaning that it had become an open wound). It also suggests that the disease could spread, leading to pulmonary tuberculosis, if it was not treated.

As the doctor advised, it was considered best for James’ health for him to be removed from the Standon Farm Home, and arrangements began to be made for James to go to hospital in London for treatment.

At the time, James’ elder brothers were still living in London and it was thought best for James to stay with them while he was receiving hospital treatment. And so in 1899, when James was 13, he was returned to his second-eldest brother William who was then aged around 25 years and was living in Lambeth in London.

A few days later, we find that James went into St Thomas’ Hospital in Lambeth for an operation. Presumably this surgery was to remove the infected lymph nodes. The success of surgery to treat tuberculous scrofula can be variable, but before the use of antibiotics it may well have been one of the only treatment options available.

Unfortunately, James’ case file ends there. Perhaps his brother William arranged James’ stay in hospital and any later care, which could be why the Waifs and Strays Society didn’t create any more correspondence about the case. If we want to know more about how James got on, a search of the records of St Thomas’ Hospital might be able to give us the outcome of his treatment there.

Detecting and preventing tuberculosis

As seen in the previous post about John who died at the age of ten tuberculosis was a very prominent disease in the early-20th Century. John died in 1905 when there was very little that could be done to combat the disease. The letter below, from November 1950, shows how things had changed in the intervening years.

Letter about the care of children who had been in contact with tuberculosis, taken from the medical file for HRH Princess Christian's Training College and Infant Nursery, Windsor, 1950

The letter was sent from one of The Children’s Society’s homes, HRH Princess Christian’s Training College and Infant Nursery, Windsor, and discusses how staff at the nursery were caring for children who had been in contact with people suffering from tuberculosis.

In this case, there were two children in the nursery whose mothers had tuberculosis. As the disease is so infectious, the children needed extra monitoring to see if they had contracted it. This highlights the fact that cases of tuberculosis were still very common in 1950, enough that specific procedures had to be put in place for those that had come into contact with the disease.

On reading the letter we can see that the children were monitored for tuberculosis by undergoing a patch test every three months. It also states that if the children were going to be returned to their parents, they should be vaccinated against the disease with the BCG (Bacille de Calmette et Guérin) vaccine. This represents a major development: in 1950, not only could tuberculosis be easily tested for, but it could be prevented through vaccination; a far cry from the ineffective preventative measures and treatments available in John’s day.

The letter comes from a medical file for HRH Princess Christian’s Training College. Similar medical files exist for a number of The Children’s Society’s children’s homes. These files generally contain correspondence about the work of the medical officers for the homes, so they detail the routine of medical tests and check-ups carried out for the children in the homes as well as containing information about a variety of other treatments, tests and diseases.

Tuberculosis and child mortality

Unfortunately, not every story has a happy ending. Today’s post is about a child named John (case number 9825), who died of tuberculosis at the age of ten.

John came from Lambeth in South London. He was an orphan. John’s father had died when John was five years old and John’s mother had died when John was eight; both had succumbed to tuberculosis. This left John in the care of his grandmother, a retired school teacher who appeared to have little money to look after him, and so, shortly after the death of his mother, application was made for John to enter the care of The Children’s Society (then known as the Waifs and Strays Society).

In 1903, John (aged eight) and his brother Reginald (aged six) entered a receiving home in Byfleet, Surrey, and were quickly transferred to Messing Cottage Home in Kelvedon, Essex.

Looking through John’s case file, the next we hear of him is in April 1905. A letter from the Messing Home states that John had been ‘ailing’ and that he had been treated with cod liver oil. Further letters say that John had been under the care of a doctor and was staying in a foster home nearby; this was presumably to quarantine him from the other children in the Messing Home to prevent any disease from spreading.

It was thought best for John to be transferred to the Waifs and Strays Society’s Nayworth Cottage Home in Hurstpierpoint, Sussex. This home was a convalescent home on the South Coast and it was hoped that the change in atmosphere and the extra care John would receive there would help him to recover.

When John arrived at the Nayworth Home in May 1905, he was described as being ‘undoubtedly tubercular, he has a bad cough & seems very weak & emaciated‘. He was prescribed port wine, brandy and ‘a very generous diet‘ in the hopes of building up his strength. We also learn that the Matron of the home had taken it upon herself to nurse him.

Unfortunately, John continued to get worse and in July 1905 there is the following letter:

Letter from case file 9825 about the state of the child's health, 1905

Letter from case file 9825 about the state of the child's health, 1905

Nayworth Home.
Hurstpierpoint.
July. 13th. 1905.

Rev. & Dear Sir.
I am sorry to tell you that
John [surname] is in a very serious
condition, & the doctor has
just told me that I might
expect a change within the
next twenty four hours.
He might rally for a few

days, but I hardly expect it.
Everything possible has been
done for him. The poor child
is now in a very prostrate
state.
Dr Meyer is from home but
his locum. has been most
attentive
I am, yours faithfully.
Elsie P. Smith.

The next item in the case file is a telegram from the Nayworth Home, 14 July 1905, saying that John died at 10:30 that morning. He was ten years old.

A further death certificate confirms that John died of phthisis (an old term for tuberculosis) and the remaining correspondence in the file relates to arrangements for his funeral.

John’s story is sad but was not, I am sorry to say, an uncommon one. The number of children suffering from tuberculosis was high in the early 20th Century, and prior to the discovery of antibiotics to combat it, the disease was often fatal. Of all the case files catalogued so far, 347 relate to children who had tuberculosis, and 133 of those children died while in the care of the Waifs and Strays Society. Doubtless more instances of tuberculosis will appear as more case files are catalogued.

The large amount of case files that mention the disease means that they make a very valuable source for research. It would be worth looking to see how the different cases compare with each other. Did children with tuberculosis often come from families where the parents had died of the disease, as had John’s, and was this related to their living conditions? How did different treatments for the disease compare with each other? In 1905, it was thought best to give John cod liver oil, port wine, brandy, a good diet, and fresh sea air. Would these still be prescribed in earlier or later cases? A study of the case files could reveal the answer.