Emeritus Professor J Williamson CBE FRCPE DSc
I was on the medical staff of East Fortune Hospital from 1951 to 1954 and was able to participate in the development of chest services for East Lothian and the Borders.
Dr W A Murray was the medical Superintendent at the time and he later wrote an autobiographical account of his experiences. This little book describes his medical career including his earlier time as Medical Assistant at East Fortune and then as Medical Superintendent. To modern readers there are some amazing differences between the way hospitals were managed in the 20s and 30s and the present. Dr Murray wrote that probably the most extreme change has been in the role of the doctor especially the Medical Superintendent who in earlier times had had almost complete autonomy. He illustrated this by the case of a male a patient who had been in East Fortune for some months with tuberculosis of the spine and was in a plaster shell for 24 hours each day. He had the effrontery to complain about the lunch which had just been served; this was reported to Dr Charles Cameron who was then Medical Superintendent. Within two hours an ambulance was summoned and he was dispatched home (still in his plaster shell)!
East Fortune was originally farmland but during the first World War it was developed as a naval air station with a special role servicing air balloons and dirigibles. The well known R34 was based there and, in time, became the first airship to cross the Atlantic.
During and after the war tuberculosis became a serious health problem in the UK and when peace came the question arose as to what should be done about it in East Lothian. Eventually a ‘Seven Counties Joint Sanatorium Board’ was formed with the task of creating a Sanatorium for these counties (East, Mid and West Lothian, Berwickshire, Peebleshire, Roxburghshire and Selkirkshire). It was agreed that East Fortune Air station should be adopted for Sanatorium use; huts and other buildings were altered and open air verandas added (in line with the fresh air treatment then in vogue). The Sanatorium was opened in 1922 with 210 beds for men and women and there were special wards for children. Most patients suffered from pulmonary TB but there were quite a lot of cases of bone and joint and glandular TB. A few patients had tuberculosis of the kidney and some unfortunates also had disease in the urinary bladder. Most cases were due to the human strain of the TB bacterium but some had been infected by the bovine strain through drinking infected milk; pasteurisation of milk had not then been introduced.
Dr Cameron was the first Medical Superintendent and was a strict disciplinarian as the case noted above illustrates. He was somewhat eccentric and Dr Murray told me that he believed that cats could be responsible for spreading TB and he conducted a campaign to rid the hospital of all stray cats. It was apparently not infrequent during ward rounds for Dr Cameron to spot a stray cat outside whereupon he would shout “Sister, the shotgun” and Sister would rush to her duty room and return with a twelve bore gun, the window would be opened and the cat duly despatched! Apparently the subsequent post mortem did sometimes reveal tuberculous glandular lesions.
In the inter war years, TB continued its slow decline but the Sanatorium continued to be busy with patients coming from the seven counties. When war came in 1939 the Sanatorium was taken over by the RAF as an airfield and proved an important part of the country’s air defences. The Sanatorium was transferred to Bangour Hospital and continued there until 1949 when it returned to East Fortune, which had been adapted for this role for the second time.
Dr Murray was, by this time, Medical Superintendent and lived in the handsome old farmhouse nearby. Dr Cameron had, meanwhile, been appointed to the Chair of Tuberculosis at Edinburgh University. This Chair had been vacant since 1939 following the death of Sir Robert Philip, one of the great pioneers of tuberculosis control and the first occupant of the Chair.
By this time tuberculosis in Scotland presented a grave problem. Throughout Europe there had been a great increase in incidence and mortality during the war due to malnutrition and privation but this was quickly reversed once peace was restored. However, in two European countries the epidemic of tuberculosis continued to worsen in the immediate post war period; these two countries were Portugal and Scotland. So far as I know no satisfactory explanation has ever been found for this phenomenon.
Whatever the reason, this post war epidemic of tuberculosis was a most serious problem for the medical services in Scotland and East Fortune was, once again, in the thick of it. Every effort was made to increase the service at East Fortune and the number of nurses and doctors was increased and beds were added eventually reaching 400. By the time I arrived there were several other medical assistants including Dr A P Littlewood, Dr Ian McLeod and later Dr Hugh McLeod. Dr Rose Donaldson was still around but was soon to retire.
Dr Murray had sought specialist help for the bone and joint cases and this was supplied by Mr Walter Mercer who later became the first occupant of the Chair of Orthopaedic Surgery in Edinburgh. Mr David Band dealt with cases of renal TB. He was a rather spectacular character who drove an elegant Rolls Royce but was also a distinguished urologist. The most important expertise was from the thoracic surgical team headed by Mr Andrew Logan supported by Mr Bobby McCormack and Mr Philip Walbaum. One of them came to the hospital every week. We presented patients to them and operations were agreed upon and duly carried out without undue delay. There was an excellent operating suite run by a first class theatre sister, Sally Logan.
The standard surgical approach to treatment was based on ‘collapse therapy’. This meant that the diseased lung (or part thereof) was caused to shrink thereby ‘resting’ it and enabling cavities to close. There were temporary forms of collapse therapy such as artificial pneumo-thorax (AP) and pneumo-peritoneum (PP). In AP air was introduced into the space between the lung and the chest wall and in PP air was introduced into the peritoneal cavity in the abdomen. In cases having PP it was usual to paralyse the phrenic nerve on the affected side. This led to paralysis of the diaphragm on that side and this then pushed up the lower part of the lung. The phrenic nerve was approached through a small incision in the side of the neck and it was crushed with forceps producing paralysis which lasted about six months. Both AP and PP cases needed regular air refills, usually weekly, and evening clinics were provided for patients who were working. Patients would have X ray screening carried out by one of the doctors, then air introduced, usually 200 or 300 ml at a time. This was done under local anaesthetic but with practice we became very deft and most patients preferred the refill needle to be swiftly entered without local anaesthetic. No-one really knows how effective AP and PP were because no controlled trials were ever carried out. I think there is no doubt that some cavities were successfully closed and lung infiltrations reduced in size by AP. I never felt very sure about PP.
These procedures were, on the whole, fairly ‘safe’ but if things went wrong with the AP it could be disastrous. The most dreaded complication was when the air filled pleural sac became infected resulting in copious pus formation (empyema). This often became chronic and sometimes ended in a lingering death. Sometimes adhesions had formed between the lung and chest wall resulting in fibrous band formation. These bands prevented the lung from collapsing and in such cases the thoracic surgeon would be asked to cut the adhesions. This was done through a small incision in the chest wall using a little telescope (thorascope) which allowed the surgeon to inspect the adhesions. A diathermy probe was introduced through another incision and used to burn through the adhesions. Great skill and experience was essential. Permanent collapse therapy was also often used. The procedure became known as thoracoplasty. In this operation several upper ribs were removed and the lung apex dissected free and thus allowed to collapse downwards and inwards. Usually the first three or four ribs were removed but in more extensive disease six or seven would be excised in which case there would be a two stage approach, the second taking place some weeks after the first. This was a fairly major operation and it resulted in some mutilation of the chest wall sometimes with later problems for the patient.
I feel fairly sure that many patients were helped by this procedure and I certainly saw a lot of long standing cavities closed with resulting ‘sputum conversion’. (This meant that a patient who had been coughing up sputum with TB bacteria in it, ceased to do so. This was a most important achievement for both the patient and those close to him). These surgical procedures were all carried out within the hospital and we all took our share of being ‘assistants’ at the operations. Dr Littlewood was responsible for most of the post- operative care, which was often quite demanding.
One of my tasks on arriving at East Fortune was to establish local chest clinics in order to cover the five counties. (The counties of Mid and West Lothian had continued to be served from Bangour Hospital after the second world war). Clinics were set up in Peebles (at the Cottage Hospital), in Galashiels and for a short time I ran a monthly clinic in Coldstream (in the back premises of the local pharmacy!). For each clinic I took a portable X ray machine which I set up and operated to provide Chest X rays. These X rays were nearly all of reasonable quality but if any other X ray procedure was needed, the patient had to come to East Fortune. One of the benefits of this scheme was that I met local GPs and other primary care staff. At one time I was driving about 2000 miles a month (mileage was 31/2d per mile – less than 2 ‘modern’ pence!) I also set up a weekly clinic in Chalmers Hospital, mainly for Musselburgh patients.
Patients were often in hospital for many weeks or months. Boredom and frustration were common and the hospital tried to provide recreation and entertainment. Here the occupational therapist was important. Handicrafts were encouraged and whenever possible professional or amateur entertainers would come to the hospital. Weekly film shows were much appreciated. Patients were allowed to have short breaks at home, usually a ‘long weekend’. Sometimes it was difficult to get them to return which was quite understandable. Infectious cases were difficult to deal with since they were a danger to contacts at home. One Edinburgh patient was a rather troublesome character because he was quite infectious but insistent upon going home rather often at weekends. One day he asked to talk to me, asking for a ‘weekend pass’. I said to him ‘but you were at home the weekend before last’. He replied ‘I want to have the weekend with my bigmouse wife’. He meant of course ‘bigamous’!
The Advent of Chemotherapy
Ever since Koch showed in 1882 that TB was due to infection with a bacterium, efforts had been made to find a substance which would kill the organism (or at least inhibit its growth). Many false claims were made and there was a fair amount of quackery and fraudulent claims. Ehrlich then discovered an arsenical compound which was effective in killing the spriochaete which caused syphilis while not being too toxic for the patients’ tissues; this was described as Ehrlich’s “magic bullet” because it hit the target without causing ‘collateral damage’. This led to an increased search for a ‘magic bullet’ for TB. Fleming’s discovery of penicillin led to the era of antibiotics and it was anticipated that it was probable that an antibiotic for TB would be found.
In 1944 American workers published an account of streptomycin which had important anti-TB properties; four years later the UK Medical Research Council reported a controlled trial of streptomycin in active pulmonary TB. This showed that this drug was highly effective in reducing the size of X ray shadows and, in some cases, caused sputum conversion. However, there were snags, the principal one being the development of resistance to the drug on the part of the TB organism. However, another drug was soon found which had anti-TB effects. This was para-amino salicylic acid (PAS) and the great benefit of this was that when streptomycin and PAS were given together, resistance did not occur. Shortly after, isoniazid was also discovered. This was cheap, had far fewer side effects and was very powerful against TB. Again drug resistance developed rapidly when this drug was given alone.
By the mid 1950s, John Crofton and his colleagues in Edinburgh had demonstrated that if all new cases were given ‘triple therapy’ virtually everyone with tuberculosis would be cured. Where patients did not respond in a satisfactory way, it was found that the reason was that they had not been taking their medication as prescribed (‘non-compliance’). The Edinburgh team published this work in 1958 but substantial numbers of colleagues refused to believe it and it was not until 1960 when a multi-centre controlled trial of triple therapy proved it, that world wide acceptance occurred.
This, of course, was a momentous and historic achievement. For the first time in history we were able to say to a patient ‘… the diagnosis is tuberculosis but we are going to cure you …’ It is impossible for young doctors, nurses or patients today to realise what an achievement this was. Prior to the chemotherapy era, we dreaded telling patients and their relatives the diagnosis not just because of the fear of illness and death but also because of the powerful stigma which the disease had acquired both in Scotland and throughout the world.
The Swiss Sanatorium Scheme
In the early 1950s Scotland agreed with several Swiss sanatoria that selected Scottish pulmonary TB cases would go to Switzerland for treatment. Dr Murray was in charge of this scheme for East of Scotland patients and East Fortune was used to admit them for assessment and thereafter as a staging post en route for Switzerland. This entailed a fair amount of extra work for the hospital and Dr Murray had to go to Davos regularly to see that patients were being well treated. We all took a share in being medical flight attendant for returning patients. The scheme was highly successful and many patients were effectively managed by the Swiss staff.
By the early 1950s the Edinburgh epidemic was still raging and there were lists of about 400 Edinburgh patients waiting for hospital treatment and so East Fortune was asked to take Edinburgh patients as well. This was successfully achieved and many Edinburgh patients were glad to be taken into hospital even if it was 20 miles outside the city.
By the time I left East Fortune in 1954, the epidemic of TB was coming under control and in the following few years, waiting lists had been eliminated. I was appointed Chest Consultant in Edinburgh with John Crofton and his colleagues. Within a couple of years we had no waiting lists for admission, thoracic surgery was very rarely needed and soon we were able to transfer beds to other specialties.
In 1959 I took the large step of becoming a geriatrician and took over some of the ‘TB beds’ in Edinburgh for the care of older patients. I feel enormously privileged to have worked in the field of tuberculosis during the 1950s when we showed that cure was very possible and I look back with gratitude to my happy time at East Fortune’.