Louisa Aldrich-Blake’s Casebook

Posted on 9th November 20189th November 2018 by Edward Wawrzynczak | Leave a comment

On 25^thApril, 1891, five-year-old Beatrice Saunders, drowsy and delirious, was brought to London’s Royal Free Hospital by her mother. Louisa Aldrich-Blake, a 25-year-old medical student, later to become an eminent surgeon, spent the next 10 days patiently documenting the progression of the little girl’s illness in her casebook (shown below). Beatrice died of tuberculous meningitis on 4^thMay 1891. Aldrich-Blake’s casebook provides us with a valuable lens through which to view the education of a nineteenth-century female medical student.

Aldrich-Blake’s casebook, Wellcome Library, MS 5794.

This casebook is part of a collection of Louisa Aldrich-Blake’s clinical notes, written between 1887 and 1908, presented to the Wellcome Library in 1926. It documents a number of patient cases that Aldrich-Blake observed as a student on the wards.

Much of Aldrich-Blake’s documentation is in keeping with Nicholas Jewson’s concept of late nineteenth century ‘Hospital Medicine’. This can be appreciated in Aldrich-Blake’s record of a complete medical examination on admission of the patient to hospital. She adopts a logical systems-based approach: ‘nervous system’, ‘alimentary system’, respiratory system’ and ‘circulatory system’ are all examined thoroughly.

There is an overwhelming preoccupation with statistical analysis by way of patient observations in Aldrich-Blake’s account. Numerical data features strongly – the number of respirations, the heart rate and the temperature being specified several times. This is further emphasised through the inclusion of the patient’s observation chart (see below). In one sense, this renders the text obsolete: the account of the deteriorating child is distilled down to numbers on a graph, an objective depiction of life and death.

Observation chart, Wellcome Library, MS 5794.

30 hours after the patient’s death, an autopsy was performed, and the findings described in great detail. Of the seven pages that Aldrich-Blake used in her casebook to record this admission, a significant proportion (one-and-a-half pages) was dedicated to the post-mortem examination. This is in keeping with Jewson’s view of pathological anatomy as integral to Hospital Medicine.

However, elements of Aldrich-Blake’s documentation also correspond with Jewson’s notion of ‘Laboratory Medicine’, for example in the testing and analysing of bodily substances. Aldrich-Blake recorded the results of Beatrice’s urine analysis in her casebook: ‘Urine: acid. No alb. No sugar. Abundant urates’.

Despite these unquestionable features of ‘Laboratory Medicine’, Aldrich-Blake’s account also contains some aspects of ‘Bedside Medicine’, notably a diagnosis achieved via the patient’s self-report of their illness. Given that the focus of this case is a five-year-old child, clearly the patient would not be expected to provide a history herself. However, the mother does give such a report, and Aldrich-Blake’s inclusion of this highlights its significance:

Quite well up till April 22^nd, no previous alteration in temperament. In the evening after coming home from school complained of headache and shivered. Early next morning had a severe fit of coughing of a peculiar character. After this she vomited and continued to do so after food or medicine until admission to R.F.H on April 25^th.

Aldrich-Blake’s casebook entry demonstrates co-existing elements of ‘Bedside’, ‘Hospital’ and ‘Laboratory Medicine’ as described by Jewson. This casebook is a rich resource for helping us understand the practices of nineteenth-century medical professionals. It also provides us with some insight into the somewhat nuanced transition from bedside to hospital medicine.

Wellcome Library, MS 5794, 5.r.

Collecting “stuff”

Posted on 28th October 201828th October 2018 by Edward Wawrzynczak | Leave a comment

Recently my wife and I have been trying to declutter our home; an emotional process that threatens domestic harmony and generates both relief and bereavement in equal measure. A lifetime of collected material artefacts and documents entombed in draws, cupboards or cardboard boxes are finally being subjected to the “William Morris test”: is it useful, is it beautiful? If not, where should it go? Relatives, friends, the sale room, eBay, charity shops, the municipal tip, or a car-boot sale are places where “stuff” can be deposited. In this way, collections become fractured, and objects might lose both their identity and meaning.

This year the BSHM has celebrated collections and collectors through an excellent Poynter lecture “the Doctor as Collector ” by Simon Chaplin which is now available on this website at https://BSHM.org.uk/poynter-lecture/ and by our recent symposium “In Sickness and in Health ” with abstracts and lecture images at https://bshm.org.uk/events/collections-symposium/

When James Parkinson (1755-1824), of eponymous disease fame, died, his collection of fossils, regarded as one of the finest in the UK, was inherited by his unappreciative wife. Sadly, she allowed the collection to be broken up and disposed of at a public sale. No catalogue exists and very few of the specimens can now be traced. A similar fate befell many other note-worthy “cabinets of curiosity” in the 18th an 19th centuries.

‘Cabinet of Curiosities’, by Domenico Remps, c. 1689

Readers of this blog may, like me, be reviewing their accumulated stuff. If you have collections or archives that could be of interest to other medical historians please take steps to deposit these in an appropriate repository – archives, libraries or museums – where they can be properly conserved, catalogued and made available to others.

Chris Derrett

The “Spanish” Influenza Pandemic of 1918-19

Posted on 11th October 201811th October 2018 by Edward Wawrzynczak | Leave a comment

In this centenary year there have been several new books, articles and television programmes about the pandemic which killed between 50 and 100 million people worldwide. Much of this writing, however, has been very America-centric, and has ignored the influenza that had been spreading in Europe from the autumn of 1916. Although this version of influenza had a low penetrance, it had a high mortality due to the fact that 25% suffered what we now know to be a cytokine storm, so 20% died a very unpleasant death. At the time it was not known what was happening – was it an infection, or some new poison gas produced by the other side? Amongst the British it almost exclusively affected soldiers, but when they discovered that German and Austrian soldiers and civilians were badly affected, the conspiratory theory was discarded. In UK there was a small outbreak in Aldershot, but it did not spread. The bacteriologists could find no common organism and labelled it “purulent bronchitis”. It was not until the 1918 pandemic, when it was noted that survivors of purulent bronchitis were immune to the influenza, that they realised they were looking at the same disease. Sadly, no tissues or samples remain of this early manifestation.

By definition “Spanish” Flu started in the USA in March 1918. This behaved in quite the opposite way to the purulent bronchitis. The mortality of the first wave (March-early September) was no higher than normal influenza epidemics, but it was extremely infectious. In the worst week, in July 1918, 46,275 British soldiers in France reported sick – they nearly overwhelmed the medical system. It was during this time that the infection got its misnomer. The warring nations did not wish to give any information to the enemy that might suggest that they had an increased rate of sickness, but Spain, which was neutral, had no such compunction. This meant that our press was able to report an epidemic in Spain, and the name stuck. The incorrect fact that it had started in Spain was believed to such a degree that when exploring the National Archives in Malta I came across the draft of a telegram from the Governor to the British Ambassador in Madrid demanding medical information. This was sent in cypher.

National Archives of Malta, CSG 01 – 1033/1918

In September 1918 it appears that the two expressions of the influenza met and mutated in Étaples near Boulogne and created the deadly 2^nd wave which caused a huge death rate as it still had the high penetrance of the American 1^st wave, but about 10% suffered the haemorrhagic cytokine storms. The figures are frightening. 17 million died in India alone, Samoa lost 20% of its population. In London 13,000 died of influenza (in 1912 the influenza deaths has been 535).

It must have been a horrendous time to be a doctor, struggling to understand why so many previously healthy young people were dying, and struggling to find places to nurse them. Many factory buildings had to be converted into makeshift hospitals. Let us all pray that we are able to contain the next severe pandemic.

Jane Orr

The First Bone Atlas—A Success or Failure?

Posted on 24th August 201828th August 2018 by Edward Wawrzynczak | Leave a comment

William Cheselden completed a surgical apprenticeship in 1709. Remaining in London, he was unable to immediately develop a practice and instead taught anatomy. He eventually turned his class notes into a book, The Anatomy of the Humane Body. It was wildly successful, partially because it was in English rather than Latin. The book proceeded through 13 editions and was the go-to source for surgical anatomy for a hundred years.

Based on his deep understanding of anatomy, Cheselden became an adept surgeon—setting fractures, removing cataracts, and extracting bladder stones. His surgical reputation rapidly spread far and wide.

Cheselden is best remembered, however, for what might be considered a failure. Understanding that skill in surgery requires a thorough understanding of anatomy, in 1733 he published Osteographia, or the Anatomy of the Bones. The book took several years and £17,000 to complete. It was the first book devoted solely to bone anatomy. It sold only 97 copies, yet Osteographia is a treasure of anatomy and artistry.

Cheselden recognized that techniques of perspective and shading were critical to rendering three-dimensional objects accurately onto paper. Just a slight shift of the artist’s head or an urge to highlight a shadowed surface distorted the results. These were outcomes that Cheselden wanted to avoid. Surgeons needed absolutely accurate representations of the skeleton. The subtleties of each contour had to be perfect.

Under Cheselden’s guidance, two artists accomplished his aim. Unique at the time for medical illustration, they suspended the bones from a tripod placed in front of a large box. A tiny hole in one end allowed light and an image of the bones to enter. One of the artists sat at the open end and traced every detail onto a glass plate, which Cheselden then converted to an engraving. At the time, the technique of using a camera obscura was unique for medical illustration. Today we recognize the device as a pinhole camera.

Osteographia ranks as one of the all-time great anatomy atlases in scope and elegance. The camera obscura, depicted on the book’s title page, signals the work’s accuracy. Osteographia’s sensitivity and elegance become quickly evident when noting the exquisite detail of the drawings, their arrangement on each page, and the lack of overlying labels or lines. The text is sparse. Cheselden knew that the images could tell their own story. They continue to do so.

Roy A. Meals, MD blogs regularly at www.aboutbone.com

New collection of medical photographs

Posted on 10th August 201812th August 2018 by Edward Wawrzynczak | Leave a comment

Thanks to a grant from the Wellcome Trust, the Historic England Archive has completed a 12 month project to conserve, digitise, and catalogue a collection of photographic prints showing health and social care in Britain between 1938 and 1943.

The Mozelle Sasson High Voltage X-Ray Therapy Department at St Bartholomew’s Hospital, 20th January 1939. (MED01/01/0123) Source: Historic England Archive

The 4,071 black and white photographs were taken by Norman Kingsley Harrison for the Topical Press Agency, and were only recently rediscovered in the Historic England Archive. The Topical Press Agency, established in 1903, supplied newsworthy photographs to the Fleet Street press and specialist journals. While it is not clear why all of the photographs in the collection were taken, it is possible that some were produced for journals such as Nursing Times. Each photograph is accompanied by a detailed caption written by the photographer, which has been transcribed and supplemented by further research.

A broad range of subjects is covered by the Medical Collection, including medical procedures, child welfare, blood transfusion, and nurses’ training. Wartime healthcare and nursing feature heavily, including auxiliary and military hospitals, improvised wards, and bomb damage.

The collection reveals a snapshot of 1930s and 1940s Britain, and shows a health service responding to the demands of a country at war. Significantly, many of the sites shown in the photographs have changed dramatically or have been destroyed or transformed, giving added significance to the collection as a photographic record.

Captivating oral history interviews with nurses who trained and worked in the 1940s and 1950s also form part of the Medical Collection, and a short film featuring the interviews and photographs has been published on YouTube.

The collection offers insights into the history of nursing, rehabilitation, specific procedures, and healthcare in the years prior to the founding of the NHS. It also provides a fascinating record of the development of social care, and documents ground-breaking medical developments during the Second World War, the beginnings of the National Blood Service, and the nursing of military casualties.

More information can be found at www.historicengland.org.uk/medical, and the digitised photographs can be viewed at archive.historicengland.org.uk by searching “MED01”. Low resolution images are available for free, and high resolution images for personal non-commercial use can be ordered free of charge. For more information about ordering, please contact archive@historicengland.org.uk

Abigail Coats, Cataloguing Officer, Historic England Archive