Outpatients at St George’s Hospital, 1733-1948

This blogpost was written by Alexandra Foulds, Project Archivist at St George’s, University of London.

How did you become an outpatient at St George’s Hospital before the creation of the NHS? What was it like to be an outpatient at St George’s Hospital at this time? Well, from its establishment in 1733 until the creation of the NHS in 1948, St George’s Hospital was what was called a voluntary hospital, which meant that it was reliant on receiving donations from ‘subscribers’ for funding. The board of governors at St George’s Hospital was made up of those who made large financial contributions to the hospital and medical staff who, unlike at most voluntary hospitals, were eligible to make subscriptions to the hospital.

In order to support themselves, voluntary hospitals ‘ran continuous appeals and publicity campaigns’, and voluntary hospitals competed with each other for funding. They would organise dinners and fundraisers which played an important part in the social calendar for donors. The expanding middle class would donate to the hospitals out of philanthropy and because of the social status it brought them. Becoming a subscriber to a voluntary hospital also meant that you could refer people to the hospital to become an outpatient or inpatient, and the amount donated equated to a certain number of referrals that were allowed per year.

Voluntary hospitals were created in the eighteenth century to give free medical treatment to the ‘sick poor’, or those who could not afford to be treated by private physicians. A distinction was made between the ‘poor’ who were considered to be self-reliant and therefore believed to be deserving of charity and the ‘destitute’ who were not. As Henry Burdett, the hospital administrator who helped to establish the British Hospitals Association in 1884, stated:

‘The people who are entitled to free relief are those who are able to maintain themselves independently of all extraneous assistant until the hour of sickness, when the breadwinner, for instance, is  struck down, or the added expense of sickness in the home renders it necessary that the hospital of dispensary should step in’.

This meant that initially to be treated as an outpatient or an inpatient at a voluntary hospital like St George’s, patients needed a letter from one of the hospital governors or a hospital subscriber that said that they were ‘proper objects of charity’, and even once patients had been accepted they were subject to suspicion that they may be abusing the system.

The outpatient department functioned alongside dispensaries to provide out of hospital medical care to poor patients on a charitable basis, and it was where the majority of what we now refer to as primary care was conducted.

Patients at St George’s mostly came from Westminster and Pimlico, both of which were largely poor, working class areas and some parts of which were slums. In 1910 St George’s Hospital reported that the majority of patients came from Westminster (Pimlico), Chelsea, Fulham and Battersea, with a few coming from further South in Clapham, and Lavender Hill (King Edward). 6% of these patients were trained servants, however, only 2 1/4% were currently employed as servants, and their average annual wage was between £21 and £22.

Photo of a newspaper clipping showing a photo of people attending the unveiling of the bust of John Hunter at the St George's Hospital Medical School, Hyde Park Corner. Not Dated.

After receiving a letter from a subscriber to the hospital, outpatients would visit St George’s Hospital. They would first be seen by a Medical Officer who would decide whether a patient was an acceptable hospital case, should be an outpatient or an inpatient, or should be treated as a casualty in which case they would be seen by a doctor immediately. The term casualty could apply to anything from ‘a small cut’ to a ‘bad toothache’, as well as those who had been in an accident. Once a patient had been accepted as an outpatient an Inquiry Officer would ask for their name, age, occupation, address, their marital status, their wages, and if they were married then their number of children that were dependent on them. In the case of patients who were children they would also be asked for information about the father, and in the case of married women they would be asked for information about their husbands.

Upon their second attendance at the hospital they would be seen by a Casualty Officer and an Almoner. The almoner could then investigate to advise on whether free treatment should be ceased and patients should be referred to workhouse infirmaries, private practitioners, dispensaries, or other hospitals. In 1910, of the 48,583 outpatients 6,768 cases were investigated, with 432 considered not suitable for treatment. The almoner could also decide along with the doctor whether home visits from volunteer ‘lady health visitors’ should be organised, or whether instruments (such as trusses for hernias) or meals should be provided, generally paid for out of the Hospital’s Samaritan Fund which was principally made up of subscriptions from hospital governors. The almoner was also responsible for coordinating with charitable societies to ensure that patients would continue to receive the care they needed outside of the hospital.

At the beginning of the nineteenth century, outpatient treatment numbers were small, however, from 1835 they began to rise and continued to rise until the beginning of the twentieth century. In the years 1833-1842, St George’s Hospital treated 70,000 cases of which 44,000 were outpatients. By 1910, St George’s treated 48,583 outpatients in that year alone, of which 67% were casualties.

As a result, doctors had to treat patients incredibly quickly, with Dr Robert Bridges, a casualty physician at St Bartholomew’s Hospital and later the Poet Laureate, writing in 1878 that he had to treat over 30,000 outpatients a year at a rate of 88 seconds per patient. By 1900, St George’s Hospital introduced a limit on how many new outpatients would be treated each day with the rest being turned away. In 1910 average outpatient attendances were approximately 160 a day, with new cases limited to 15 per hospital department per day, with all patients being seen first by a superintendent who imposed the limit when they arrived at the hospital. If a patient was not one of the 15 but was considered to require treatment he was brought back the next day.

Photo of the outpatient department at St George's Hospital at Hyde Park Corner.

As outpatient departments provided free access to health care, they were viewed as being in competition with private physicians and were therefore seen as a threat to the physician’s income. This meant that in medical journals outpatient departments, and voluntary hospitals more generally, were frequently described as locations in which patients abused the medical system by getting free care when they could afford to be treated by a private doctor.

By the end of the nineteenth century several voluntary hospitals, St George’s among them, was choosing not to require a letter from a hospital subscriber for outpatients (Louden), and so physicians tried to introduce the requirement for patients to be referred to the hospital by private practitioners in order to prevent this perceived abuse of the system. A letter to the British Medical Journal in 1894 stated that:

‘The abuse of the hospitals’ outpatient departments is an evil so gigantic that the tendency is to regard it […] as necessary in the sense of being unavoidable […] The remedy lies in the hands of those who suffer most from the unfair competition of the hospitals, and it is idle to appeal to the public or to the hospital authorities. […] The remedy I would suggest (though I claim no originality) would be to admit to the outpatient department only patients whose cases are certified by some medical authority or medical man to require special consideration’.

In 1910, however, only 3-6% of outpatients at St George’s Hospital were referred by physicians.

These perceived abuses led in 1910 to an investigation into the admission of outpatients in hospitals in London by the King Edward’s Hospital Fund for London, who from 1897 gave funding to voluntary hospitals. They called on people from various medical charities and representatives from each of the voluntary hospitals to testify, asking about the suitability of the letter system, hospital procedures for dealing with outpatients, the numbers of outpatients and the kinds of cases hospitals treated, and whether they believed the system was being abused by patients. William West, the treasurer at St George’s at the time, testified, arguing that he did not believe that the system was abused at St George’s, but that there were times it was misused by patients who had paid to be treated by a physician and upon seeing no improvement wanted a second opinion and so visited the hospital.

In 1948 the NHS Acts brought voluntary hospitals under public ownership, however, researchers have argued that it is these nineteenth and early twentieth century arguments about the relationship between hospitals and private physicians that led to our current NHS health system in which patients are required to be referred to specialists in hospitals by their GP.


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#MorbidAdvent: What Did We Learn?

Opening Up the Body’ is a Wellcome-funded project to conserve the Post Mortem Examinations and Case Books of St George’s Hospital, 1841-1946. Our Archive team have been cataloguing and digitising records dating from 1841-1921. This post was written by Project Archivist Alexandra Foulds, with contributions from Project Archivist Natasha Shillingford and Archivist Juulia Ahvensalmi.

St George’s University of London Museum and Archives Instagram post on smallpox as part of #MorbidAdvent
St George’s University of London Museum and Archives Instagram post on smallpox as part of #MorbidAdvent

In December 2020 we decided to do an advent calendar on social media in which we would use every day to highlight a disease or condition that could be found in our post mortem casebooks. Calling it #MorbidAdvent, throughout the month we covered:

When we started, we assumed that these were conditions that had been relegated to history but the morbid nature of all these diseases was brought into stark relief with the realisation that none of the diseases apart from smallpox (thanks to the efforts of Edward Jenner) have actually been eradicated.

Vaccinations are, of course, of particular interest and relevance at the moment, and there are vaccines for many of the diseases we examined, including tuberculosis, rabies, influenza, whooping cough, tetanus, diphtheria, measles and smallpox. Others, such as malaria or leprosy can be treated with various medications.

Despite this, many of the diseases remain common outside of the Western world. 10 million people were diagnosed with tuberculosis in 2019, predominantly in South-East Asia, Africa, and the Western Pacific, resulting in 1.5 million deaths. There were an estimated 229 million cases of malaria in 2019, the majority of them in sub-Saharan Africa: children are particularly vulnerable to the disease. Diphtheria, despite mass immunisations in the UK in the 1940s, is still common in Africa, India and Indonesia, with a 5-10% death rate affecting mainly children. Measles, which has an alarmingly high R number of 12 to 18, similarly caused over 140,000 deaths in 2018, mostly in children under 5 years old. Cholera outbreaks remain common in Africa, South America and Asia. In 2008-2009 an outbreak in Zimbabwe killed 4200 people and in 2010-2011 another in Haiti caused 6631 deaths. In all of these places, a lack of access to health care, poor water quality and poor sanitation allow for contagious diseases to take hold and spread.

As these diseases have not been eradicated they frequently resurface in the United Kingdom. There are still around 12 new cases of leprosy diagnosed each year in the UK and the World Health Organisation states that in 2018 there were 208, with 619 new cases of leprosy diagnosed worldwide. This is approximately one every two minutes. In 2019 the notification rate for TB in the UK was 8.4 per 100,000 of the population. Even smallpox has the potential to return, as it did in 1978, as it is retained in laboratories.

It is not only contagious diseases that can have resurgences. Rickets, for example, which is caused by a vitamin D deficiency, despite mostly disappearing in the UK in the 1950s with mass programs of cod liver oil for children, has recently experienced a comeback that has been attributed to children spending more time indoors and the use of sun creams whenever they are outside.

Photo of the post mortem record of Ethel Almond who had rickets and then contracted tubercular meningitis (PM/1888/314). Archives and Special Collections, St George’s, University of London.

The post mortem record of Ethel Almond who had rickets and then contracted tubercular meningitis (PM/1888/314). Archives and Special Collections, St George’s, University of London

Patients at St George’s Hospital

Visualisation of the causes of death found in the post mortem casebooks of St George’s Hospital 1841-1887 created using Flourish. Archives and Special Collections, St George’s, University of London.
Visualisation of the causes of death found in the post mortem casebooks of St George’s Hospital 1841-1887 created using Flourish. Archives and Special Collections, St George’s, University of London.

When we started the advent calendar we knew that the period covered by our post mortem casebooks (1841-1946) was punctuated by numerous outbreaks, epidemics and global pandemics of various contagious diseases. The most notable of these that affected the UK included:

Cholera: 1831-1832, 1838-1839, 1848-1849, 1853-1854, 1866-1867

Influenza: 1830-1831, 1833, 1836-1837, 1847-1848, 1857-1858, 1889-1890 (Russian/Asiatic Flu), 1918-1920 (Spanish Flu)

Smallpox: Large epidemics in 1837-1838 and 1870-1874 (after the Franco-Prussian War). 1901-1902 was the last outbreak in London. (England was declared rid of smallpox in 1939).

Scarlet fever: 1892-1893. Particularly common at the beginning and ends of the nineteenth century.

Diphtheria: 1850-1860

While trying to find cases of these diseases in the post mortem casebooks, however, we were struck by the fact that there were far fewer cases than we had expected, even in years when there were epidemics. This was despite many contagious diseases being more easily caught by people with malnourishment, a condition from which it is likely that many of the patients at St George’s would have suffered. St George’s Hospital’s nineteenth-century position at Hyde Park Corner meant that many of its patients came from Westminster and Pimlico, both of which were very impoverished, working-class areas of London at this time. Wealthier patients in nearby St James’s, Belgravia and Mayfair would have been more likely to have been treated by visiting physicians (some of whom would have also worked at St George’s) in their own homes. Hospitals had been created in the UK in the eighteenth century to serve the ‘deserving’ working class poor and were considered, at least until the late nineteenth century, to be dirty and sources of contagion, so people tended to stay away if they could. The extremely poor who were unable to support themselves, considered to be ‘undeserving’, would have been treated in workhouse hospitals.

Fever hospitals

Trying to account for this low number of contagious diseases in our post mortem casebooks led us to find out about fever hospitals, or hospitals set up in the nineteenth century specifically to treat contagious diseases. Prior to this only a small amount of hospitals were willing to take contagious patients. A smallpox hospital had been created in Windmill Street off Tottenham Court Road in 1746, and patients with other contagious diseases could be sent to one of the Royal Hospitals or to Guy’s Hospital. As part of the nineteenth-century public health movement, 12 fever hospitals were created in London, starting with the Institution for the Care and Prevention of Contagious Fevers (later called the London Fever Hospital) at Grays Inn Lane in 1801. While the majority of these were on land, between 1883 and the end of the nineteenth century three of them were converted ships (the wooden warships the Atlas and the Endymion, and the iron paddle steamer Castalia), which were moored on the River Thames and used to treat smallpox patients. Patients who needed to be treated in a hospital were sent to one of these fever hospitals after being referred by a doctor, and were only treated in hospitals such as St George’s if their condition was not apparent when they were admitted. Once their condition was diagnosed, we can see from the medical notes in our post mortem casebooks that they were moved to separate wards. One of the fever hospitals, however, the Grove Fever Hospital which opened in 1899, was sited where St George’s Hospital is now in Tooting. Two of the ward blocks survive to this day.

Photograph of Grove Fever Hospital. Archives and Special Collections, St George’s, University of London.
Photograph of Grove Fever Hospital. Archives and Special Collections, St George’s, University of London.

Highlights of the advent calendar

A few of the conditions covered in the advent calendar proved to be particularly interesting and unusual, such as glanders, leprosy, and malaria.

Glanders

Glanders is an unusual disease in the Morbid Advent Calendar as it is a zoonotic disease. In other words, Glanders primarily occurs in horses, mules and donkeys but can be transmitted to humans by direct contact with an infected animal’s body fluid and tissues, and can enter the body through skin abrasions. The majority of patient’s in the post mortem volumes who contracted Glanders, were stablemen, horse keepers and grooms.

Despite the fact that the last confirmed case in Great Britain was in 1928, it still remains a very real threat, particularly as a biological weapon during war and has long been a threat to armies. It is believed that Glanders may have affected the horses of Marshall Tallard’s cavalry prior to the Battle of Blenheim in 1704 which helped the Duke of Marlborough to win the battle. It is also believed that during World War I, Russian horses on the Eastern Front were deliberately infected with Glanders by German agents. More recently, the Soviet Union allegedly used the germ that causes Glanders during the Soviet-Afghan War.

Unlike many of the diseases featured in the calendar, there is currently no vaccine for Glanders. The lack of a vaccine, the fact that the disease is not widely known and is therefore difficult to diagnose, the ability for the germs to be released into the air, water or food supply, and the germ’s resistance to common antibiotics makes the bacteria a significant bioterrorism threat.

Leprosy

Photo of manuscript showing a leper. Wellcome Collection. Attribution 4.0 International (CC BY 4.0)
Manuscript showing a leper. Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

The earliest possible account of a disease which is believed to be leprosy appears in an Egyptian papyrus document written around 1500 BC. The first account of the disease in Europe occurs in the records of Ancient Greece after the army of Alexander the Great returned from India.

Leprosy had entered England by the 4th century AD and was a common feature of life by 1050. However, it seemed unusual to find a case of leprosy in London in 1884, particularly as the last case of indigenous leprosy in the United Kingdom was diagnosed in 1798.

Further research uncovered that it wasn’t until 1873 that Dr Gerhard Henrik Armauer from Norway identified the germ that causes leprosy and proved that it was not a hereditary disease or a punishment by God, but an infection caused by bacteria. It is now curable with a multidrug therapy which was developed in the early 1980s.

Malaria

The post mortem record of John Lee who is described as having ‘lived in an aguish district near Eastbourne’ (PM/1891/87). Archives and Special Collections, St George’s, University of London.
The post mortem record of John Lee who is described as having ‘lived in an aguish district near Eastbourne’ (PM/1891/87). Archives and Special Collections, St George’s, University of London.

From ‘mal’aria’, or bad air, malaria was so named as it was thought to be caused by miasma. The connection between mosquitoes and malaria was not established until the 1890s; Patrick Manson, the first lecturer in tropical diseases at St George’s Hospital Medical School and the founder of the London School of Hygiene and Tropical Medicine, was instrumental in developing the so-called mosquito-malaria theory.

Far from being confined to hot, faraway countries (though the postmortems show that the majority of the cases were contracted by soldiers, seamen and colonial officers in India, the West Indies, China or the United States), the postmortem books reveal cases in places like Deptford, Hampshire and Eastbourne: it turns out that malaria was, in fact, a significant cause of death in Britain. In these cases, the diagnosis is often given as ‘ague’ or ‘marsh fever’. Decrease of marsh wetlands and increase in cattle as well as improvements in housing, drainage and ventilation (factors which affect also many other causes of death during this period) and water chlorination led to malaria gradually disappearing as an endemic disease in Britain (the last cases occurred in Stockwell in 1953).

Quinine, derived from the bark of cinchona tree, has been used to treat malaria since the 1600s, and the origins of gin & tonic is often said to be as an anti-malarial drug, though this is not strictly true. Quinine is still used to treat malaria, although there are now various other medications too.

What did we take away?

Finding out more about these diseases put the current Covid-19 pandemic in a new light. While it is easy to think of our current situation as exceptional, what our advent calendar made clear was that it is something that humans have experienced many times before and continue to endure in many parts of the world. While it might be easy to find this thought quite bleak, it helped us to feel more positive. Like all outbreaks of contagious disease, this too shall pass, and as our history and our experience over the last year shows, we have the ability to band together to make great medical advancements when we have the drive to do so. Current technology has enabled us to experience this pandemic in a global way that has never been seen before and hopefully this unity will continue as we try to vaccinate the world’s population. Perhaps this will carry forward and enable us tackle other diseases together, giving new impetus to strategies such as the World Health Organisation’s plan to cut new cases of TB by 90% and reduce deaths by 95% by 2035.


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#ExploreYourArchive: St George’s Archives

This week we’re celebrating Explore Your Archives, an initiative designed to showcase archives around the UK. You can follow the day using the hashtag #ExploreYourArchive as well as on St George’s archives and museum social media on Twitter, Instagram or Facebook. This blogpost was written by St George’s Archivist Juulia Ahvensalmi.

The history of St George’s reaches all the way back to the early 18th century. With a history tightly interwoven with that of St George’s Hospital, it is impossible to talk about the history of St George’s without talking both of the medical school (what is now the university) and the hospital.

St George’s Hospital, Hyde Park Corner in the 18th century and in the early 20th century. Archives and Special Collections, St George’s, University of London.
St George’s Hospital, Hyde Park Corner in the 18th century and in the early 20th century. Archives and Special Collections, St George’s, University of London.

The hospital was established at Hyde Park Corner in 1733, and it wasn’t until the 1970s that both the medical school and the hospital were relocated to Tooting. Initially located in the seemingly idyllic countryside setting of the Hyde Park, the hospital was built as a charity hospital, to serve the poorer part of the population. Difficult as it may be to imagine now, the patients came primarily from the slums of Westminster (what is sometimes known as the ‘Devil’s Acre’) and the surrounding area, and our post mortem records show for instance how the 1854 cholera epidemic in Soho resulted in a spike of deaths at the hospital.

Post mortem records, 1854 (PM/1854) showing deaths caused by cholera and a visualisation of the death rate during the epidemic, created from the data in the records using Flourish. Archives and Special Collections, St George’s, University of London.
Post mortem records, 1854 (PM/1854) showing deaths caused by cholera and a visualisation of the death rate during the epidemic, created from the data in the records using Flourish. Archives and Special Collections, St George’s, University of London.

Our student records are a veritable treasure trove for the history of St George’s and its alumni. From the early days, surgeons and physicians were permitted to take on pupils. The first student records date from 1752, although the medical school itself wasn’t formally established until 1834. These volumes record the attendance of medical luminaries such as Edward Jenner, who was a pupil at St George’s in the 1770s under John Hunter. Besides other well-known names, such as Henry Gray, the records continue to be a valuable source for learning more about the history of St George’s and its alumni.

‘Register of pupils and house officers, 1756-1837’ (SGHMS/4/1/18), and Edward Jenner’s entry in the pupil register, 1770. Archives and Special Collections, St George’s, University of London.
‘Register of pupils and house officers, 1756-1837’ (SGHMS/4/1/18), and Edward Jenner’s entry in the pupil register, 1770. Archives and Special Collections, St George’s, University of London.

Much of the history of St George’s appears to be very white, very male, and very elite – medical education was not for everyone. Sometimes we get asked who, for instance, was the first BAME student at St George’s, which is a question we cannot, unfortunately  answer with any degree of certainty – the early student records consist mainly of only names, and although we hold some student photographs from as early as the 1860s (such as this photograph depicting the dissecting room), the records in the archives do not tell us of the ethnic origins of the students in any systematic way.

The archives can, however, reveal less well-known, but important and fascinating aspects of this history. We have highlighted, and will continue to highlight, these stories in our social media posts, from Hajee Baba, who may have been the first Muslim student at the Medical School in 1807; to Assaad Y. Kayat, a Lebanese student at St George’s in the 1840s, who studied alongside Henry Gray, and wrote a book about his life and his medical studies in England; to Henning Grenander, a Swedish figure skater and masseuse, who was a student at St George’s in 1896; to Helen Ingleby, one of the first female students at St George’s in 1915; to Kathryn Hamill Cohen, a psychoanalyst and one of the first female students at St George’s after the Second World War.

Assaad Y. Kayat, a student at St George’s in the 1840s, and Kathryn Hamill Cohen, a student at St George’s in the 1940s. Archives and Special Collections, St George’s, University of London.
Assaad Y. Kayat, a student at St George’s in the 1840s, and Kathryn Hamill Cohen, a student at St George’s in the 1940s. Archives and Special Collections, St George’s, University of London.

Even more importantly, we continue to collect student records so future users of the archives will perhaps look with the same awe at the records of the cohort of 2020 as we now regard the early student records – and that history will look very different from the early history of the institution.

Many and varied collections

The archives are also a home to a variety of other items that tell the story of St George’s. We have a sizeable collection of rare books, including Edward Jenner’s ‘Causes and Effects of Variolae Vaccinae’ (1798) and John Snow’s ‘On Chloroform and Other Anaesthetics’ (1858). From the 16th to the 20th century, this collection has been accumulated by the library over the years at both Hyde Park Corner and Tooting, and is now held in the archive.

Edward Jenner, 'Causes and Effects of Variolae Vaccinae' (1798), showing the hand of Sarah Nelmes, a dairymaid whose cowpox pustule Jenner used to vaccinate the son of his gardener, 8-year old James Phipps, demonstrating that cowpox could provide immunity from the more dangerous smallpox. Blossom, the cow in question, is still at the SGUL Library. Archives and Special Collections, St George’s, University of London.
Edward Jenner, ‘Causes and Effects of Variolae Vaccinae’ (1798), showing the hand of Sarah Nelmes, a dairymaid whose cowpox pustule Jenner used to vaccinate the son of his gardener, 8-year old James Phipps, demonstrating that cowpox could provide immunity from the more dangerous smallpox. Blossom, the cow in question, is still at the SGUL Library. Archives and Special Collections, St George’s, University of London.

There are various artworks (some of the busts and paintings are featured at Art UK website) and a large photograph collection, which includes photographs relating to the school and the hospital as well as other hospitals and institutions closely associated with St George’s. These include Atkinson Morley’s, which was originally built as a convalescent home for St George’s patients (who were initially transported to Wimbledon by horse-drawn carriages). Latterly it was known for its neurological centre, with neurosurgeon Wylie McKissock at its helm. The archives also holds oral history recordings, including an interview of McKissock talking about his career and experiences at St George’s and at Atkinson Morley’s.

Staff and patients at Atkinson Morley’s, 1934; and the bust and surgical kit of Benjamin Brodie held in the archives. Archives and Special Collections, St George’s, University of London.
Staff and patients at Atkinson Morley’s, 1934; and the bust and surgical kit of Benjamin Brodie held in the archives. Archives and Special Collections, St George’s, University of London.

Another fascinating collection is our artefacts: from anatomical models to surgery kits, the collection tells of the fascinating history of medicine. The surgery kit displayed below, awarded to a St George’s student called Edward Walker in 1856, includes amputation knives, a trephine and bone forceps, among other items. It can be regarded with a new level of trepidation when we realise that antiseptics and anaesthesia were still being developed, which made surgery of any kind a horrifying prospect for the patient; John Snow was one of the early adopters of ether and chloroform in surgical anaesthetics at St George’s. And to demonstrate that medical advances often take their time, despite Jenner’s smallpox vaccination, smallpox was not eradicated until 1976 – and one of the items held in the archive is Professor Harold Lambert’s smallpox testing kit from the 1950s.

Surgical kit, 1856 and smallpox testing kit, 1950s. Archives and Special Collections, St George’s, University of London.

Online and digital

We recently explored our digital futures in this blog and the links we can make to the past and to our heritage through the archives (in this case, connections between records relating to COVID-19 and influenza epidemics of 1918 and 1889).

We continue to catalogue our collections, and to make them available online via our online catalogue. Our flagship project on St George’s historical post mortem records (which you may have heard of if you’re following us at all, as we do like to talk about it!) is in full swing, with Project Archivists Natasha Shillingford and Alexandra Foulds cataloguing and making available online new volumes of post mortem cases.

Perhaps paradoxically, they give us a glimpse to the lives of those who rarely get a voice, and whether you’re interested in anatomical illustrations (some executed with some artistic flair), medical treatments (such as champagne, gin and ether or belladonna and arsenic), 19th century occupations, casual racism and prejudices exhibited by the doctors, colonial patterns of travel and immigration, mental health in the 19th century or pastry chef murderers, follow us on social media and get in touch – we’re always happy to hear from you!

Is there anything else you’d like to see or find out? Get in touch with us at archives@sgul.ac.uk or via our social media channels, and we will do our very best to answer any questions you may have.

The Founder of Post Mortem Examinations at St George’s, University of London

Opening Up the Body’ is a project to conserve the Post Mortem Examinations and Case Books of St George’s Hospital, 1841-1946. Our Archive team have been cataloguing and digitising records dating from 1841-1917 – that’s about 27,132 cases across 76 volumes. The comprehensive reports contained within these volumes reveal some fascinating stories, which we’ll be sharing with you via the Library blog. Today’s post comes from Natasha ShillingfordProject Archivist.

Photograph of portrait of Sir Prescott Gardner Hewitt, Archives & Special Collections, St George’s, University of London
Photograph of portrait of Sir Prescott Gardner Hewitt, Archives & Special Collections, St George’s, University of London

‘It is not the oil-painting which adorns the walls our board-rooms…which will cause him so vividly to abide in our memories as, perhaps the unrivalled collection of pathological experience which this Hospital possesses, and which we owe to the initiation of Sir Prescott Hewett. For it is to him we are indebted for the inauguration of the system of recording the post-mortem records of the Hospital, which had now remained in force for over fifty years, and which has endowed us with a collection of pathological experience perhaps unrivalled in the medical world. This is a monument which will ever remain and will be ever associated with the name of Hewett.’ (‘Distinguished St George’s Men’, St George’s Hospital and Medical School Gazette, Vol III, Issue 25)

Post mortem examination signed by Prescott Hewett, PM/1842/104. Post Mortem Casebooks, Archives and Special Collections, St George’s, University of London
Post mortem examination signed by Prescott Hewett, PM/1842/104. Post Mortem Casebooks, Archives and Special Collections, St George’s, University of London

Prescott Gardner Hewett was born on 3rd July 1812, the son of William N W Hewett of Bilham House, near Doncaster, by his second wife. His father was a country gentleman whose fortune was said to have suffered from his love of horse racing. Hewett received a good education and spent some years in Paris where he trained in the studios, having first decided to become a professional artist. However he became acquainted with the son of an eminent French surgeon and he became inspired to joint the surgical profession himself. He studied anatomy in Paris before returning to England.

Upon his return he entered St George’s Hospital where his half-brother Dr Cornwallis Hewett had been Physician to the hospital from 1825-1833. The excellence of his dissections caught the attention of Sir Benjamin Brodie, and he was appointed Demonstrator of Anatomy and Curator of the St George’s Hospital Museum around 1840. The first record in his handwriting was dated 2st January 1841. It was said that his ‘lucidity of expression, his clear and graphic exposition of his subject, his apt illustrations, and above all his facile and ready pencil, which served to demonstrate the most complicated anatomical point, soon gained him recognition and esteem of his class.’ (‘Distinguished St George’s Men’, St George’s Hospital and Medical School Gazette, Vol III, Issue 25)

It was during his time as Curator of the Museum that the post mortem records that are currently being catalogued as part of the Opening up the Body project were first commenced by Hewett. Also, many of Sir Benjamin Brodie’s preparation in the Museum were put up by Hewett.

He was appointed Lecturer on Anatomy in 1845 and Assistant Surgeon on 4th February 1848. He became full surgeon on 21st June 1861, in succession to Caesar Hawkins, and Consulting Surgeon on 12th February 1875.

He was also elected President of the Pathological Society of London in 1863, and ten years later he occupied the Presidential Chair of the Clinical Society. Amongst his other positions, he was appointed Surgeon Extraordinary to Queen Victoria in 1867, Sergeant-Surgeon Extraordinary in 1877, and Sergeant-Surgeon in 1884 in succession to Caesar Hawkins. From 1867 he also held the appointment of Surgeon to the Prince of Wales, and afterwards King Edward VII. On August 6th 1883 he was created a baronet.

Hewett was also Arris and Gale Professor of Human Anatomy and Physiology at the Royal College of Surgeons from 1854 to 1859, a Member of the Council from 1867 to 1883, Chairman of the Board of Examiners in Midwifery in 1875, Vice-President in 1874 and 1875, and President in 1876.

On 13th September 1849 Prescott Hewett married Sarah Todmorden, eldest daughter of the Rev. Joseph Cowell, of Todmorden, Lancashire, by whom he had one son and two daughters. He died on 19th June 1891 at Horsham, where he had retired after being created a baronet.

Few men have ever left the world with a more stainless record of duty honestly done and of success won by no ignoble means.

(‘Distinguished St George’s Men’, St George’s Hospital and Medical School Gazette, Vol III, Issue 25)


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From servants to soldiers, from agriculture to administration: occupations in St George’s Hospital Post Mortem casebooks, 1841-1918

Opening Up the Body’ is a project to conserve the Post Mortem Examinations and Case Books of St George’s Hospital, 1841-1946. Our Archive team have been cataloguing and digitising records dating from 1841-1917 – that’s about 27,132 cases across 76 volumes. The comprehensive reports contained within these volumes reveal some fascinating stories, which we’ll be sharing with you via the Library blog. Today’s post comes from Dr Juulia AhvensalmiProject Archivist.

Post mortems? Surely they’re all about death and misery? In this blog post I hope to show that is not the (only!) truth. I want to examine what else historical post mortems can tell us, and illustrate how they contain a wealth of information about not just the deaths, but also the lives of the patients. The post mortem volumes held in the archives of St George’s, University of London provide a fascinating glimpse to the social structures of 19th and early 20th century central London. So let’s see what the collection can tell us about the patients of St George’s Hospital in the 19th and early 20th centuries. What did they do for living? How did big changes in the society such as the industrial revolution and the First World War show in the lives of Londoners at this time? I’ll use visualisations to give an overall picture, and zoom in to look at the people behind the statistics, so sit back – get your cup of tea ready – let’s go to Hyde Park Corner.

Engraving of St George's Hospital and Constitution Arch
St George’s Hospital and the Constitution Arch, Hyde Park Corner. Engraving. Credit: Wellcome CollectionAttribution 4.0 International (CC BY 4.0)

Most of the post mortem cases record the occupation of the patient, and this is one of the details we have been keeping a track on whilst cataloguing the volumes. The image below shows an overview of occupations from the volumes finished so far, ranging from 1841 to 1918; the data has been visualised using Flourish, and you can explore the graph in more detail by zooming in, and filtering the data by year to take a closer look.

Flourish data visualisation
Source: Post Mortem Casebooks, Archives and Special Collections, St George’s, University of London. By Juulia Ahvensalmi

The largest categories are in the building and construction trade (general labourers, painters, carpenters), and in domestic service (servants, cooks, housemaids). Other categories include food and accommodation services (people working in public houses, hotels and restaurants), food industries and sellers of food (grocers, bakers, butchers), people working in occupations relating to agriculture (largely stablemen, grooms as well as gardeners and farm labourers) and industries and manufacture (from smiths to window blind makers) and transport (drivers, railway workers and so on). The classification is a simplified version of ‘The occupational structure of Britain 1379-1911’ by the Cambridge Group for the History of Population and Social Structure.

It’s not always clear what category is most appropriate – unless the record explicitly states that someone works for instance as a servant at a hotel, rather than at a private house, it is impossible to know. ‘Servant’ has therefore been classified as ‘domestic service’, with the caveat that this might not exclusively be the case. The category ‘miscellaneous services and occupations’ include what it says on the tin – a selection of occupations that do not fit neatly the other categories, often because they were rare within the data, or because it is not clear which category they should belong in. The latter category includes things like apprentices (who were they apprenticed to?) and collectors (what exactly were they collecting?). Amongst them there is a wonderful array of occupations: there’s a mosaic worker from 1870, an assistant secretary of the Conservative Club from 1918, a piano forte maker from 1877, a keeper of urinal from 1858, a sword polisher from 1888 and a cats’ meat man from 1858. The latter would have sold meat for cats, probably walking around the streets with a cart (one can only imagine the cats trailing after him!). Rosa Blacker in 1858 is ‘Clergyman’s daughter’, and Louisa Lee in 1887 is just described as ‘gypsey’ (there would also be a lot to say about the use of language in the records, often startling and offensive to the modern reader).

The hospital at this period was located at Hyde Park Corner: the site was not closed until 1980. The building still stands, but instead of a hospital it now houses a luxury hotel. Knightsbridge, Kensington, Chelsea, St James’s, Mayfair, Soho – these days that part of London doesn’t suggest the working class population that the occupational data highlights here. But although Hyde Park Corner, then as now, had an abundance of large, wealthy households, these houses required servants, as well as people working in the local shops and factories. Some of the areas which we may now connect with wealth and opulence were not always like that; the notorious slum around Westminster, for instance, was dubbed the ‘Devil’s Acre’ by Charles Dickens. The so-called poverty map by Charles Booth, a businessman and social reformer, published 1886-1903, shows the area around Hyde Park to be largely wealthy and middle class, but towards Westminster and Chelsea there are areas in which the population is classed from ‘poor’ to ‘very poor, casual. Chronic want’ and ‘lowest class. Vicious, semi-criminal’.

Charles Booth's Poverty Map
Charles Booth’s poverty map of the area around Hyde Park Corner. Source: Charles Booth, © 2016 London School of Economics and Political Science. Map data © OpenStreetMap contributors

Accidents and diseases are frequently a direct consequence of people’s occupations, and the post mortems enable the tracking of occupational diseases. Painters often suffered from colic, or lead poisoning, and paper stainers also frequently dealt with toxic substances: John Hyland, 48, is noted as having handled during his working life ‘much lead, arsenic, copper & mercury’ – a paper stainer would have worked with wallpaper, which, due to its vivid colours, was notoriously deadly in the Victorian era. Falling off scaffolding or ladders is a frequent cause of death for builders, and in 1888 we find the case of Aaron Gatheridge, 53, who, as a carpet layer, had ‘swallowed many nails and tacks’ (he died of cancer of the pylorus).

Preconceptions and prejudices about certain occupations as well as classes can also be seen in the post mortems. Those working in the hospitality industry in particular were often assumed to be heavy drinkers, and the doctor treating David Ferguson, 45, in 1888 notes that ‘He was a butler but claimed to be considered temperate’, whilst George Carter’s, 45, medical record in 1860 states that ‘This man was an omnibus driver of drunken habits, like most of his class’. Some positions also came with certain benefits, as we learn from the case of George Courtenay, 38, in 1860: ‘He was a very sober man, though he partook freely of the beer which was allowed in unlimited quantity to the servants’ (sobriety is also a relative concept).

Post Mortem record of Mary Fitzgerald 2 Mar 1905 PM/1905/57
Post Mortem record of Mary Fitzgerald, 2 Mar 1905 PM/1905/57. Post Mortem Casebooks, Archives and Special Collections, St George’s, University of London

Of Mary Fitzgerald, aged 35 in 1905 it is noted that ‘Her life had always been sedentary – that of a needlewoman’. Another aspect of 19th century life the post mortems reveal is social and geographical mobility. Sarah Black was only 15 years old when she died of tuberculosis. She is described as being a kitchen maid, and her medical case notes tell us that she had come to London from Argyleshire two years previously, presumably to find work in the city. The doctor notes that ‘She was a dark-haired Highland girl with a fair skin’.

Not everyone was, however employed: unemployment was also a problem, and with no social security available apart from poor houses and charity hospitals, unemployment often meant destitution. The case notes of Samuel Brooks, 24, tell us that at the time of his admission to the hospital suffering from tuberculosis, ‘he had been out of work a long time, & starving, that he had recently found employment, and it was supposed he had been unequal to his task. He had been ailing for a fortnight, and had been entirely laid up for a week’. William Chant committed suicide in 1887, aged 57, after a period of unemployment; his notes tell us that ‘in consequence [he] had got very depressed’.

The class divide

The class divisions were stark: if you were wealthy enough, you would pay for a doctor to visit you at home, or attend their private practices. Only those who could not afford it went to the hospitals, which were often filthy and unhygienic.

Post Mortem record of Agneta Le Strange, 3 Oct 1918, PM/1918/207
Post Mortem record of Agneta Le Strange, 3 Oct 1918, PM/1918/207. Post Mortem Casebooks, Archives and Special Collections, St George’s, University of London

There are occasional exceptions to this rule in the post mortem records: among the occupations of the hospital patients we find some gentlemen, a couple of ladies, an admiral and a naval commander, for instance. But looking further into these cases, they all turn out to be accidents or a sudden disease. The evocatively named Agneta le Strange was brought to the hospital unconscious by the police in 1918 after suffering a sudden brain haemorrhage; not a heroine in a gothic novel or a wizard as her name might suggest, Agneta was presumably visiting the family’s London townhouse in Eaton Square (the family also had a mansion in Norfolk). In the majority cases, the bodies, though recorded in the post mortem volumes, were not autopsied, as that was another marker of social status: the choice to not have a post mortem. H.J. Blagrove, a ‘gentleman’, was ‘flung from his horse near the hospital’ in 1854, but his relatives asked that his body would not be examined, apart from his skull, which had been injured in the accident.

Occupations in SGUL post mortem examination books, 1858. Source: Post Mortem Casebooks, Archives and Special Collections, St George’s, University of London. By Juulia Ahvensalmi

The earliest of the post mortems from the 1840s only record patients’ occupations sporadically, often when it has some bearing to their disease. As we proceed further in time, the registrars start recording the occupations more methodically. Decades before cars filled the streets of London, horses were an important feature in everyday life, as the presence of grooms and stablemen shows; cab drivers, carmen and coachmen were employed in driving the horse-driven carts or cars around the capital. A gardener might have worked somewhere like the Vauxhall Pleasure Gardens, Chiswick Garden or Hyde Park, for instance, or in any number of plant nurseries providing plants to aspiring gardeners in the capital – there are even occasional farm labourers among the patients. Many people are employed in the building and construction: London was rapidly growing and these skills were in demand. There are fruiterers, bakers, butchers, distillers; people work in hotels, restaurants,  coffee houses, pubs (‘potman’ collected and washed dirty pots and glasses in a public house); they cook and serve; sew dresses, make cabinets and wigs and saddles; the charwomen and street sweepers clean and take care of public places as well as private houses.

The gender divide

Women’s occupations in SGUL post mortem examination books, 1841-1918. Source: Post Mortem Casebooks, Archives and Special Collections, St George’s, University of London. By Juulia Ahvensalmi

Women did not have many occupations open to them on their own right. When in employment, they were, by and large, working with textiles as dressmakers, needlewomen and milliners, and in domestic service, as servants, housemaids, cooks, laundresses and cleaners. Towards the late 19th century industrialisation means some other occupations become available for women, such as working in factories, and in particular during the First World War we start seeing clerks, secretaries and typists among the women. Lilly Grundy, 19, is recorded as having been a ‘machinist’, probably in a shoe factory. For unmarried women with children, the options were even fewer, and for most of the 19th century limited to dressmaking and cleaning. The post mortem records usually note the occupation of the father for the children; recording the occupation of the mother instead signals to the reader that the mother was unmarried. The mother of Edwin Cannon, aged 4 in 1887, was a charwoman (or cleaner), and the mother of Pat Gurney, aged 5 in 1917, was a flower seller, indicated in the post mortem records by ‘M’ for ‘mother’.

Index to the post mortem volume 1887, showing the entry for Edwin Cannon, PM/1887/120, and index to the post mortem volume 1917, showing the entry for Pat Gurney, PM/1917/266. Post Mortem Casebooks, Archives and Special Collections, St George’s, University of London

This was also the time when St George’s Medical School allowed its first female students, several of whom went on to work at the hospitals, including on the post mortems. Mostly, however, women’s status was defined by that of their husband or father; they are designated as ‘wife of labourer’, ‘wife of coachman’, or simply ‘married’, ‘wife’ or ‘widow’. And looking more closely into the cases it is soon obvious why this would be. Lack of (knowledge of) contraception as well as the social unacceptability of it meant that many women spent much of their lives pregnant, breastfeeding and caring for their children – they simply did not have the chance to even consider working outside the home. Emma Rickets, 50, is recorded as having had 22 children in 1888 – and having been one of 22 herself. That is of course an extreme example – but 10 children is not uncommon, and surely much fewer would have been stressful enough. Maria Cooper was 27 when she died in 1860; she is noted to have been married at 15 and borne nine children before her untimely death.

War and bureaucracy

Soldiers and sailors make occasional appearances in the records, often in the form of men who had perhaps gone ‘to sea’, often in East India Company’s employ, and latterly returned to Britain from the colonies. James Scott, for instance, died aged 44 in 1881. His occupation is listed as a confectioner, but his medical case notes tell us that he had gone to sea aged 17 in East India Company’s service, and had suffered from dysentery whilst in India. Life at sea is laid bare in the description of Scott as ‘a very heavy drinker of spirits, especially 1858-1870 when he had much morning vomiting & depression’. Far fewer are references to people who made the journey in the other direction: John Lusila was only 23 when he died in 1854 of tuberculosis. His medical record notes that ‘This poor black, who was a native of Angola, and had been in the West Indies, had been 10 years in England, & was a waiter in an eating house’.

Post mortem record of John Lusila, 17 Dec 1854, PM/1854/384. Post Mortem Casebooks, Archives and Special Collections, St George’s, University of London

From the Napoleonic wars in the early 19th century to the First World War, the post mortems record soldiers, their wives and their children. In the visualisation of the occupations in 1918, the armed forces has become the largest category: there are soldiers, privates, riflemen, sergeants, a captain, a naval commander and an admiral – and in particular their wives and children, who of course were the ones remaining in London.

Occupations in SGUL post mortem examination books, 1917. Source: Post Mortem Casebooks, Archives and Special Collections, St George’s, University of London. By Juulia Ahvensalmi

The visualisation also shows a huge increase in the types of occupations, compared to the earlier chart of 1858. In addition to the categories seen earlier – domestic service, occupations relating to the food industries and hospitality, building and construction – the industrial revolution, as well as the war, is apparent in all the jobs in factories: machinists, munition workers, aeroplane makers, electric fitters. There are also more white-collar type jobs in administration (clerks, secretaries, typists); there are engineers, a barrister, an architect, a bank manager and so on. The biggest change, however, is in the ‘other’ category, which earlier was filled with married women; in 1918, this category only includes two widows and one housewife.

Hélène Crosmond-Turner in Various musical celebrities by and after Elliott & Fry bromide print, 1890s. NPG Ax139913 © National Portrait Gallery, London

One of the interesting categories are those working in arts and entertainment. There are not many, but they include Percy Vaughan, a comedian, who died of tuberculosis aged 29 in 1887. His medical case records laconically that ‘he had been a pantomimic actor & had lived hard and fast’. Another tragic story is that of an opera singer, Hélène Crosmond-Turner. Born Rosa Levison or Leverson, she shot herself in a cab on Piccadilly in 1888 after failing to renew her contract as a lead in Aïda. She had for some time been worried about her financial situation and her career, and had tried some days previously to overdose on painkillers. The papers made much of this dramatic suicide, including describing her dress in detail – red and brown stripes, with a black and brown checked ulster, trimmed with imitation beaver (‘not one of her best outfits, as her landlady Mrs Godbold later observed’). Part of the attention lavished at poor Hélène following her death was due to her famous mother, Madame Rachel, whose tagline was ‘beautiful forever’. From selling rabbit skins and used clothes in London’s East End, Rachel proceeded to be the owner of a very profitable beauty salon in Mayfair. Her famous cosmetics, however, contained a multitude of toxic chemicals, including prussic acid, lead and arsenic. This, alongside with allegations of blackmailing her clients, led her to being prosecuted for fraud. She died in Woking jail in 1880, aged 60, eight years before her daughter.

What other stories would you like to hear from the post mortem project? We’re lucky in that we have all the volumes digitised, so we’re able to continue cataloguing the cases, and are eager to hear your views!

A Case of Leprosy in the Archives

Opening Up the Body’ is a project to conserve the Post Mortem Examinations and Case Books of St George’s Hospital, 1841-1946. Our Archive team have been cataloguing and digitising records dating from 1841-1917 – that’s about 27,132 cases across 76 volumes. The comprehensive reports contained within these volumes reveal some fascinating stories, which we’ll be sharing with you via the Library blog. Today’s post comes from Natasha Shillingford, Project Archivist.

The post mortem record of Amy Bradshaw, Archives & Special Collections, St George’s, University of London, PM/1884/9

Amy Bradshaw, a seven-year-old girl, was admitted to St George’s Hospital on 24th July 1883 and she later died on 10th January 1884. She was suffering from Leprosy.

The medical case notes record that ‘Her mother was a native of Oxfordshire, her father of Barbados, where his family had lived for three generations since leaving Scotland.’ Amy was one of six children, one of whom died in infancy of dysentery, and two had Leprosy. The sister next above her in age was four and a half years older, and she developed symptoms of Leprosy in 1875. Amy was said to have first developed symptoms herself in 1879, when her mother noticed raised spots ‘like blind boils’ on her back and thighs, which after a time turned brown and were succeeded by a fresh crop.

On admission she was described as ‘a dark intelligent child of characteristically leprous aspect. Over the face and hand the flattened tubercles, in parts red, in parts brown, are abundantly scattered: the nose enlarged, flattened at the tip, red and pigmented; the lower lip the same.’ On her arms, legs and feet were depressed cicatrices and scattered dark brown pigment.

On examination the larynx and epiglottis were found to be thickened and unnaturally white and a lumpy deposit was found. ‘The timbre of the voice is somewhat nasal and the vowel sounds slightly continental.’

Amy was treated with Chaulmoogra Oil in the form of an emulsion which was seen as a success and the child was happy as a rule, although she occasionally complained of soreness and aching in the leprous tubercles. On 17th December her temperature rose rapidly ‘when an acute invasion of the new growth set in with much pain and suppuration.’ The medical case notes report that Amy’s elder sister who was suffering from the same symptoms, was allowed to leave the hospital on 23rd December to spend Christmas at home. However, she developed pneumonia shortly after and died on 6th January. Amy also gradually developed pneumonia in the hospital and ‘sank with great pain, and high fever, dying in Jan 10 1884.’ The post mortem report states ‘Face disfigured by leprosy cicatrices.’

Leprosy affects the nerves, respiratory tract, skin and eyes. It can cause loss of fingers and toes, gangrene, ulcerations, skin lesions and weakening of the skeleton. If left untreated, it can lead to a loss of sensation in the hands and feet. This lack of ability to feel pain can lead to the loss of extremities from repeated injuries or infection due to unnoticed wounds. Leprosy can also damage the nerves in the face which causes problems with blinking and eventual blindness. Other symptoms, which can be seen in the case of Amy Bradshaw, include flattening of the nose due to destruction of nasal cartilage, and phonation and resonation of sound during speech.

Credit: Elephantiasis graecorum, True Leprosy. Chromolithograph.
Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

The disease takes its name from the Greek word λέπρᾱ (léprā), from λεπῐ́ς (lepís; “scale”). Leprosy has a long and complicated history and for centuries has been associated with social stigma, which even in the modern day continues to be a barrier to self-reporting and early treatment.

The earliest possible account of a disease which is believed to be Leprosy appears in an Egyptian papyrus document written around 1500 BC. Indian texts from 600 BC also describe a disease that resembles Leprosy. The first account of the disease in Europe occurs in the records of Ancient Greece after the army of Alexander the Great came back from India, and then in Rome in 62BC which coincided with the return of troops from Asia Minor.

Leprosy had entered England by the 4th century AD and was a common feature of life by 1050, although throughout its history it has been feared and misunderstood. It was often believed to be a hereditary disease, or some believed that it was a punishment or curse from God. Pope Gregory the Great (540-604) considered people with Leprosy to be heretics.

Others thought that the suffering of lepers echoed the suffering of Christ and they were enduring purgatory on earth and would go straight to heaven when they died. Therefore, they were considered closer to God than other people.

Leprosy patients were often stigmatised and shunned by the rest of society. During the middle ages people suffering from Leprosy were made to wear special clothing, ring bells to warn others of their presence, and walk on a different side of the road.

Credit: Manuscript showing leper. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

A passage from Leviticus 13: 44-46 shows the biblical perception that people with leprosy were unclean and should be ostracised from society:

the man is diseased and is unclean. The priest shall pronounce him unclean because of the sore on his head.

Anyone with such a defiling disease must wear torn clothes, let their hair be unkempt, cover the lower part of their face and cry out, ‘Unclean! Unclean!’ As long as they have the disease they remain unclean. They must live alone; they must live outside the camp.

Credit: Two lepers receiving food through a wall. Etching by Gaitt after A. Decamps. Credit: Wellcome Collection. Attribution 4.0 International (CC BY 4.0)

Even in more modern times, patients with Leprosy were often confined to colonies called Leprosariums because of the stigma of the disease. Some of these colonies were situated in remote lands or islands, such as the island of Spinalonga off the coast of Crete which was used as a leper colony from 1903 to 1957. The novel ‘The Island’ by Victoria Hislop tells the story of the leper colony on Spinalonga and its inhabitants.

In 1873 Dr Gerhard Henrik Armauer from Norway identified the germ that causes Leprosy. The discovery of Mycobacterium Leprae proved that leprosy was not a hereditary disease, or a punishment by God, but an infection caused by bacteria.

Patients with Leprosy were often treated, as can be seen in the case of Amy Bradshaw, with oil from the chaulmoogra nut. The treatment was said to be painful and its success was questionable, although some patients appeared to benefit. Leprosy is now curable with multidrug therapy (MDT) which was developed in the early 1980s

The last case of indigenous leprosy in the UK was diagnosed in 1798. Leprosy can no longer be contracted in this country, but there are around 12 new cases diagnosed each year. The World Health Organisation (WHO) (https://www.who.int/news-room/fact-sheets/detail/leprosy) figures state that in 2018 there were 208,619 new cases of leprosy diagnosed. This is approximately one every two minutes.


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Hysteria in the archives

Opening Up the Body’ is a project to conserve the Post Mortem Examinations and Case Books of St George’s Hospital, 1841-1946. Our Archive team have been cataloguing and digitising records dating from 1841-1917 – that’s about 27,132 cases across 76 volumes. The comprehensive reports contained within these volumes reveal some fascinating stories, which we’ll be sharing with you via the Library blog. Today’s post comes from Juulia Ahvensalmi, Project Archivist.


Elizabeth Greed was 51 years old in 1888 when she was admitted to St George’s Hospital. Her medical case history, which survives in her post mortem record in the archives, tells us that she was married and had had five children; one of them had died. Another one was said to have tuberculosis, and one was said to be a ‘cripple’. When she was young she was said to have suffered from hysteria and scarlet fever.

Elizabeth herself said that about five years before, whilst walking in her garden, she had suddenly lost power in her legs. Although she recovered from this incident, she had been knocked down in the street the previous summer, and had struggled walking ever since. She also complained of various other ‘abnormal sensations’, including tingling in her limbs and a constricted feeling in her chest. She felt like she was floating in water when sat down, and when she walked, she could not feel the ground. She was also annoyed by a constant smell of sulphur.

She went to ask for treatment at Guy’s Hospital, but, feeling ill-treated there, took a cab to come to St George’s Hospital instead, then located at Hyde Park Corner. She was received by a young doctor called Richard Sisley, who in his notes describes her as ‘olive-skinned’ and her manner as ‘hysterical’. He says she only appeared to be able to walk supported, describing her movements resembling those of a marionette. He thought many of her symptoms pointed to hysteria, although the loss of power and the involuntary movements of her legs were suggestive of ataxic paraplegia – a condition that can be hereditary, or caused by damage to brain or the spinal cord, and is characterised by loss of motor function in the lower extremities.

The post mortem record of Elizabeth Greed, Archives & Special Collections, St George’s, University of London, PM/1888/132

Elizabeth was admitted as an in-patient to the hospital on 7 March 1888. Further examinations found no abnormalities in her heart or lungs, but she was becoming increasingly paranoid and delirious. She thought she was being poisoned by turpentine mixed in her food. She was worried she would be sent out of the hospital, but she also thought that the ward she was in was filled with paraffin and would be set on fire. She lost weight, becoming increasingly weak, until she was unable to stand. On 11 April 1888, ‘she died without first symptoms, quietly’. The cause of death was recorded as possible mania and dementia, and ataxic paraplegia.

The case notes in the post mortem record of Elizabeth Greed do not elaborate more on her alleged hysteria, but her case gives us a glimpse of how women’s health was approached: despite her symptoms pointing to a physical condition, her behaviour is labelled as hysteric. Life in the 1880s London was not easy, and this was particularly the case for the poorer part of the population. We can assume that Elizabeth was poor, as those able to pay would not have attended a charitable hospital such as St George’s – they would have had the doctors come to them, or visited them at their private practices instead. The census records reveal that Elizabeth was from Clapton, and her husband Robert had moved to London from Taunton in Somerset. They lived in Bermondsey, which in the 19th century was a buzzing industrial hub, specialising in tanning, leather working, cotton work and food processing. All this industry meant that the population in Bermondsey was largely poor: the factories offered employment, but it was not particularly secure or well paid. Elizabeth is described as a ‘needlewoman’ (other related occupational terms include ‘dressmaker’ and ‘seamstress’). This was often work that could be done from home: sewing and mending clothes, making it easier for the women to care for their families. It was also, however, work that was very much underpaid, and the working conditions were likely to have been dire, with insufficient light and long hours, whether the work was done at home or in a factory.

But why was she labelled hysteric? Hysteria is no longer part of the medical vocabulary, but in the 19th century it was a common way to describe and diagnose what was perceived as emotional excess, primarily of women (this usage of course still continues outside medical diagnoses). It was seen to affect women from all social classes. The term encompassed a variety of symptoms, including anxiety, nervousness, agitation and demonstrations of sexual desire. Sexuality was at the heart of the condition; the word hysteria comes to English via Latin hystericus, from Greek ὑστερικός (husterikós, “suffering in the uterus, hysterical”), from ὑστέρα (hustéra, “womb”). Hysterical symptoms were thought to originate in the womb, and a commonly cited method of treatment was said to involve using a vibrator in order to gain release in the form of orgasm – this, however, is a myth rather than a commonly employed treatment.

Brodie, Benjamin. 1837. Lectures Illustrative of Certain Local Nervous Affections. St George’s, University of London Archives. Credit: Juulia Ahvensalmi

St George’s also plays a part in the history of hysteria. Benjamin Brodie, one of the most eminent doctors of his time and physician to the royal family, examined cases of ‘nervous affections’ in 1837. In these cases, patients had suffered from articular pain and swelling, but there had been no deterioration of bone or cartilage in the post mortem examination. In Brodie’s view these cases were neurological disorders, perhaps following a minor injury or a strong emotional experience, which could lead to a ‘hysterical knee’, for instance.

Another St George’s doctor writing about hysteria was Robert Brudenell Carter, who worked as an ophthalmologist at St George’s in 1870-1883. In his 1853 book ‘On the Pathology and Treatment of Hysteria’, he (unlike most of his contemporaries) emphasized the effect of emotions on the nervous system, arguing that a strong emotion might lead to a hysteric attack even in otherwise healthy women, as well as men. The prevalence of hysteria among women could, in his view, be explained by women’s heightened emotions, but also due to their having to suppress their emotions more than men, who were allowed to be physically and sexually more active.

The association of hysteria with the nervous system rather than the uterus, and with psychological, rather than physical, causes became more widely accepted during the 19th century. Jean-Martin Charcot was instrumental in re-defining hysteria in terms of neurological disorders, and his use of photography at the Salpêtrière asylum in Paris created controversial imagery of female hysteria.

Jean-Martin Charcot demonstrating hysteria in a patient at the Salpetriere. Lithograph after P.A.A. Brouillet, 1887. Credit: Wellcome Collection. CC BY

The American neurologist Silas Weir Mitchell advocated the so-called ‘rest-cure’ to calm the overstimulation of mind, which he believed was the cause of hysteria. This treatment was made infamous by Charlotte Perkins Gilman in her short story ‘The Yellow Wallpaper’ in 1891:

“John is a physician, and perhaps—(I would not say it to a living soul, of course, but this is dead paper and a great relief to my mind)—perhaps that is one reason I do not get well faster.

You see, he does not believe I am sick!

And what can one do?

If a physician of high standing, and one’s own husband, assures friends and relatives that there is really nothing the matter with one but temporary nervous depression—a slight hysterical tendency—what is one to do?

My brother is also a physician, and also of high standing, and he says the same thing.

So I take phosphates or phosphites—whichever it is, and tonics, and journeys, and air, and exercise, and am absolutely forbidden to “work” until I am well again.”

John W. Ogle, a physician at St George’s, discusses the case of Sarah G., 20, who was admitted to St George’s Hospital in 1869. She stated that she had been coughing and vomiting for about a year, and she had never menstruated until three weeks before her admission to the hospital. She had been treated previously at other hospitals for pain in the abdomen and vomiting. Ogle describes her as ‘rather delicate and interesting-looking’, and her manner as ‘somewhat sly and hysterical’.

Caption: John William Ogle (1824-1905), physician at St George’s Hospital. Credit: US National Library of Medicine

She was fed beef-tea and milk with limewater: beef broth was standard hospital fare, and the limewater was intended to relieve indigestion. Her constipation was treated with a ‘blue pill’ and the herbal remedies colocynth, senna draught and calumba; she was also given spirit of ammonia and bicarbonate of potassium. The so-called blue pill was (rather than Viagra!) a mercury-based medicine commonly used for this purpose, but also for treating a wide variety of other complaints, including syphilis, toothache and tuberculosis. Later various other medical concoctions were attempted, including calomel (mercury chloride), edemas made of castor oil and rue, belladonna (‘beautiful woman’ in Italian, from its cosmetic use for dilating pupils, the plant is also known as the deadly nightshade, and was used by the Roman empress Livia Drusilla to poison her husband emperor Augustus), brandy, prussic acid and morphine – it’s a wonder she was still alive at this stage, one might think!

Although her condition did not appear to be improving, she was seen to get up from her bed to watch Queen Victoria pass by the hospital on her way to open Blackfriars Bridge. This convinced Ogle that she must have been faking her illness. Despite her continued refusal to eat, she vomited and evacuated her bowels. Ogle quotes in his article a letter allegedly written by her to another patient, asking her to bring her a ‘nice peice [sic] of bread’ and to take care that she should not be seen to do so. She was further treated with faradisation (muscle stimulation by electric currents), and she was given daily baths until she got her period; she was also forced to do some exercise by walking her to the middle of the ward and then ‘leaving her to scramble back to her bed’. She appears to have got into disagreements both with the ward nurse and with Ogle, her doctor, until one day she suddenly walked out of the hospital.

Ogle diagnoses this case as ‘temper-disease’, suggesting that the original symptoms relating to her lungs may have been real enough to begin with, but that the attention received from exhibiting these symptoms had led the patient to feign further, imaginary, symptoms. He describes his patient as ‘by nature self-willed, with a ‘naughty’ disposition, badly trained, too well pleased to attract and receive attention, of an hysterical temperament’. Quoting Benjamin Brodie, he suggests that it is possible that even the cough was a hysterical symptom – a hysterical lung, if you will.


If you are interested receiving updates from the Library and the St George’s Archives project, you can subscribe to the Library Blog using the Follow button or click here for further posts from the Archives.

Libraries Week 2019: Celebrating Archives

Libraries Week takes place between 7th – 12th October 2019. This year’s campaign is focused on celebrating the role of libraries in the digital world. Over the course of the week we’ll be introducing you to different teams within the Library and explore how they use technology to support our community.


Today’s post comes from our Archives team, who have been involved in a large-scale digitisation project – so this year’s Libraries Week theme offered a perfect opportunity to provide an update! Click here for previous posts from our Archives.

Opening Up the Body: Digitising, cataloguing and visualising post mortem case books

Opening Up the Body is a project to conserve the Post Mortem Examinations and Case Books of St George’s Hospital, 1841-1946, and to catalogue and digitise those dating from 1841-1917 – that’s about 27,132 cases across 76 volumes. The catalogue data and digitised images will be made available on the St George’s, University of London website.

Post mortem of Caroline Parker, 42, from 1865.

The volumes contain manuscript case notes and detailed reports of the patients’ medical history, including details of treatments and medicines administered to patients. They also contain comprehensive reports of the pathological findings made during the detailed examination of the body after death. These rich and detailed post mortem records are a unique resource, which will contribute to our understanding of medical education, death practices, and the history of London’s hospitals and infectious diseases, amongst other things. Moreover, the volumes feature notable physicians and surgeons, including Henry Gray, who compiled his influential ‘Gray’s Anatomy’ whilst performing post mortems at St George’s.

Meet the team

Two Project Archivists have now started to catalogue the post mortem volumes and the project team consists of the University Archivist, Carly Manson, and two Project Archivists, Juulia Ahvensalmi and Natasha Shillingford.

How do we use technology to support our users?

AtoM (Access to Memory)

AtoM (Access to Memory) is a web-based, open source, standards-based application for archival description and access. AtoM was originally built with support from the International Council on Archives to encourage broader adoption of international standards for archival description across institutions. AtoM is a dynamic open source application with a broad user base who work together to continually improve and enhance the software to the benefit of the whole community.

Our catalogue is made available via the St George’s Archives & Special Collections website: https://archives.sgul.ac.uk/. AtoM allows users to type keywords into the search box located at the top of the banner, or they can explore the collections by browsing via collection, people and organisations, archival institutions, functions, subjects, places or digital objects. The catalogue homepage also displays the most popular items that have been searched for that week, which provides a glimpse into the interests of our researchers.

Each individual post mortem is being catalogued according to international standards and a summary of each will be produced, providing searchable keyword access. The information being captured in the catalogue includes the name of the patient, occupation, gender, date of admission, date of death, the physicians and surgeons who attended the case, a transcription of the diseases affecting the patient, and notes from the medical and post mortem examinations.

Example post mortem catalogue record

The catalogue data from the Opening Up the Body project will be imported from spreadsheets into AtoM.  The digitised images will be linked to the individual catalogue entry, allowing researchers to access the collection remotely and therefore increase access to the collection and also preserve the physical volumes.

Subject access points are being identified using the Medical Subject Headings (MeSH) database (https://meshb.nlm.nih.gov/search), which will allow researchers to search and identify cases by disease and anatomy group. For example, at the click of a button a researcher will be able to identify post mortems that were related to diseases of the respiratory system, or patients that were admitted to the hospital following an injury.

Name access points are also being created for every surgeon and physician of St George’s Hospital who treated the patients or undertook the post mortem examinations, and will be linked to their authority record in the catalogue. The authority record will list information such as dates of existence and a biographical history of the key figures in the history of St George’s.

Visualising the post-mortems

Word cloud of commonly found words in a post-mortem volume from 1887 using Wordclouds.com (https://www.wordclouds.com/)

As we catalogue the material, we are collecting a large amount of data. In order to be able to get the most out of this incredibly rich source, we’ve modified our cataloguing templates to structure the data so that we can both export it into AtoM in the required and easily readable format, and to make it easier to properly explore that data and gain new insights into the material.

This also requires standardising the data, especially when it comes to the names of diseases. These can change over time: tuberculosis, for instance, may be called tuberculosis or phthisis, and we want to make sure we can track these conditions, regardless of what they’re called (this of course is not always that simple, but that may be a subject for another blog post!).

Packed circles showing groups of diseases in 1864, using Flourish (https://app.flourish.studio/templates)

There are plenty of free, open-source tools available, many developed specifically for digital humanities. Visualisation tools are great for immediate visual effect, for telling stories and for drawing attention to details that might otherwise be missed, or might be worth more in-depth exploration – why does the word ‘India’ appear so frequently in the word cloud above, for instance? Why did so many people die of cardiovascular and respiratory diseases? Visualisations are nothing new, of course – John Snow (who at one time worked at St George’s) managed to figure out the cause of the 1854 cholera outbreak by mapping the cases.

Line graph showing instances of death from cholera during the 1854 cholera epidemic in London, using Flourish
Sankey diagram illustrating distribution of diseases by gender in 1864, using Flourish

As we continue cataloguing and collecting more data, we can begin to explore changes over time and ask more questions – did people live longer? How do their occupations change? How do medical advances affect the kind of diseases featured in the post mortems? How do the post mortems themselves change? Presenting the material like this not only allows our readers insights into the contents of the post mortem records, but it also gives us a chance to reflect on the details of our work, and on the ways in which we are dealing with the data as we go along. More importantly, though, we can use these visualisations to bring the material to life – so to say!

We are only just starting, so look out for more exciting visualisations as we delve deeper into the post mortems! And feel free to get in touch with us at archives@sgul.ac.uk – we’ll be happy to answer any questions you may have about the project and accessing the material.


If you are interested receiving updates from the Library and the St George’s Archives project, you can subscribe to the Library Blog using the Follow button or click here for further posts from the Archives.

St George’s Library Then & Now: 1998

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Libraries Week takes place between the 8th – 13th October 2018. Over the course of the week we’ll be exploring our Archives to look at how the library has – and hasn’t! – changed over time.


In this final retrospective look at the Library, we’ve delved into a really interesting commemorative brochure produced by library staff to celebrate 21 years of being based in Tooting.

Back in the early 1990s staff were singing the praises of their “several CD-ROM machines, word processing facilities and a scanner” which warranted instating an enquiries desk where library staff could be on hand to answer IT related questions.

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It’s interesting to note that even with the differences and improvements in technology over the past 20 years, many of the enquiries that helpdesk staff answered back in 1998 will be very familiar to users and helpdesk staff today!

Needless to say the type of enquiries facing the library staff are mainly computer related. The most common ones are

‘My Printer is not working’
‘The printer has stopped printing half way through’
I can’t open my file on the computer’

The rest of the commemorative brochure makes for an interesting read: it captures a pivotal point in the development of modern academic libraries as the way we access information began to rapidly change. Technology has streamlined many library services whilst also generating new challenges – especially over the two decades that have passed since the publication of this brochure.

For example, the move from print to electronic journals has had a fairly dramatic impact on the physical layout of the library. With most journal subscriptions now online, we no longer require the rows and rows of shelving to accommodate print copies and can offer far more study spaces, which is of real benefit to our users.

 

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The Library now manages access to thousands of journal titles, far in excess of what we ever could have accommodated physically in print, giving staff and students at St George’s access to far more content than before, with the added convenience that in most cases it can be accessed from anywhere and at any time.

However, with online journals the Library typically licenses the content for a specific period of time, whereas with print journals we owned the volumes and issues of the journals we purchased. Our Journals team must negotiate the terms and conditions of these licences with our suppliers each year, making these transactions far more complex.

Supporting access to online subscriptions also requires maintaining a number of key systems, such as our link resolver, which generates the links through to the full text of articles we have access to; either from search results in Hunter or our other healthcare databases.

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The Library also needs to manage the process of authentication: whereby journal sites identify a user is from St George’s and entitled to access that particular resource. The Journals team work hard to make this process as smooth as possible and provide the necessary support for users where difficulties arise. Responding to the pace of change as technologies develop is a real challenge for library staff and will undoubtedly continue to shape the academic library of the future.

On a final note, the brochure also offers interesting snippets of social history too. Present day staff thankfully have much more input over their own sartorial choices!

1977-98 Library Brochure trousers

…and female staff are now permitted to wear trousers for the task.

 


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If you are interested receiving updates from the Library and the St George’s Archives project, you can subscribe to the Library Blog using the Follow button or click here for further posts from the Archives.

 

 

St George’s Library Then & Now: 1977

LibWeekRGB
Libraries Week takes place between the 8th – 13th October 2018. Over the course of the week we’ll be exploring our Archives to look at how the library has – and hasn’t! – changed over time.


In this exploration of the Archives, we’re looking at some of the physical incarnations of the Library throughout St George’s illustrious history. Today the hospital and medical school are located in Tooting, but until the 1970s were situated in central London at Hyde Park Corner.

The Library at Hyde Park had many traditional features: lots of dark wooden furniture, high shelving, and books behind glass cabinets. There also appear to be desks perched very precariously on the balcony below the lovely domed ceiling, which today might cause all manner of health and safety headaches.

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As St George’s moved to Tooting in 1976, the Library settled into a more modern looking space. These photos, from 1977, give us a sepia-toned glimpse into the Library as it was then: slightly more accessible shelving, hundreds of print journals, much lower ceilings and a slightly sterile looking staff office. That said, the black and white image in the slideshow below shows a much brighter, wider study space that isn’t that dissimilar to the library back in 2012, before our last refurbishment.

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Do you have any pictures taken in or around the library from your time studying at St George’s? Whether it was last year or 20 years ago, we’d love it if you could share them with us!

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If you are interested receiving updates from the Library and the St George’s Archives project, you can subscribe to the Library Blog using the Follow button or click here for further posts from the Archives.