THE ESTABLISHMENT OF SANITARIA FOR PULMONARY DISEASES In the Vicinity of our Great Cities. BY VINCENT Y. BOWDITCH, M. D., Attending Physician to the Carney Hospital ; Physician to Out- patient Department at the Boston City Hospital; Instructor in Boston Polyclinic. Reprinted from the Boston Medical and Surgical Journal of February 25, 1892. DAMRELL & UPHAM, Puri.ishf.rs, 283 Washington Street. BOSTON: 1892. THE ESTABLISHMENT OF SANITARIA FOR PULMONARY DISEASES IN THE VICINITY OF OUR GREAT CITIES.1 Attending Physician to the Carney Hospital, Physician to Out-pa- tient Department at the Boston City Hospital, Instructor in Boston Polyclinic. BY VINCENT Y. B0WD1TCH, M.D., The treatment of pulmonary diseases in sanitaria established for the purpose, has been for a number of years a well-recognized method in Europe, especially in Germany, aud, during the past few years, the foun- dation and success of institutions in various parts of the United States, shows that the hopes of those who originated the idea were not vain, and that much more can be done now than heretofore in combatting the ravages of consumption. To Hermann Brehmer should be given the credit of having established the first institution of the sort, about thirty-two years ago, in Gbrbersdorf, a little vil- lage of Silesia, situated in a well-sheltered mountain valley about 1,600 feet above the level of the sea, where phthisis was never known to arise, and where Brehmer himself recovered his health. He conceived the idea of establishing there an insti- tution to be devoted to the treatment of pulmonary diseases only, aud although ridiculed and maligned to an outrageous degree at first by members of his own profession, he finally proved that his views were cor- rect aud his name and memory now are honored throughout Germany and elsewhere in the medical world. Since then, and upon the same principle, the famous 1 Read before the Section for Clinical Medicine, Pathology and Hygiene of the Massachusetts Medical Society, Suffolk District Medical Society, December 16, 1891. 2 sanitarium at Falkensteiu, in the Taunus Mountains near Fraukfort-on-the Main was established under the care of Dettweiler, and later, many smaller institutions have sprung up in various parts of Germany, all de- voted to the same purpose, and although varying per- haps in details of treatment, they carry out the same general idea that good food, fresh air and strict super- vision to prevent the results of indiscretion, in diet and mode of life, are the chief factors in restoring the patients to health. Under these methods both Brehmer and Dettweiler claim that fifty per cent, of the incipient cases of pulmonary disease have been cured. It was my good fortune in the summer of 1889 to see both of the above-mentioned sanitaria, and I can testify to the great care and pains shown by those in charge of the institutions. Brehmer’s sauitarium at Gorbersdorf, is a lasting monument to a noble man. Beginning as a small cottage for two or three patients, a little over thirty years ago, the institution now com- prises two immense red-brick, Gothic buildings, with accommodations for two hundred or more patients; a large winter garden, reading-rooms, etc., in addition to various small villas scattered about the grounds for wealthier patients. Beautiful gardens surround the houses and a magnificently wooded park with carefully graded paths extending for many hundreds of acres over the sides of the mountains, forms a delightful pleasure-ground for the use of the patients. In both of these institutions the strictest watch is kept over the general treatment of the patients, in re- gard to diet, amount and kind of exercise, and methods of life generally. At Gorbersdorf, after a light and early breakfast consisting of a cup of tea, coffee or milk, with bread and butter, exercise in the open air is prescribed and regulated according to the ability or 3 disability of the patient. When the patient’s strength admits of it, a walk up the mountain-side through the park is advised. To facilitate this, paths are laid out with the greatest care at a very gentle grade, seats being provided at mauy points, and the patients are told to stop and rest frequently to avoid undue fatigue, and at the same time to enable them to get the benefit of increased expansion of the chest and quickened cir- culation, so important in cases of pulmonary disease. Even in the height of winter is this made possible, as the paths are cleared of snow every morning by eight o’clock, up to the top of the mountaiu. About eleven o’clock a more substantial breakfast is served, dinner at two, and supper about half-past six, the intervening time being occupied by exercise or rest in the open air, the patients even in the coldest weather, well wrapped up, reclining in chairs for hours during the day. The moral welfare of the patients is cared for also, and frequent concerts, readings, games and other forms of amusement make an important feature of the treatment. The same general methods are carried out at Falkenstein, and although the institution has not yet reached the magnificent condition of Gorbersdorf, everything is done for the comfort and welfare of the patients. it is a significant fact in favor of sanitarium treat- ment, that although the climate of Gorbersdorf differs decidedly from that of Falkenstein, yet the favorable results are about the same in both places. In Gor- bersdorf they are blessed with infinitely more sunshine than in Falkenstein, which although situated at about the same altitude as Gorbersdorf, and on the sheltered side of the mountain, has the characteristic wet, gloomy weather of a German winter. 4 Opinious differ at present as to the effects of alti- tudes per se in their beneficial effect upon pulmonary disease; some observers maintaining that it is one of the most, if not the most important factor in the large percentage of cases of recovery reported in regions over 1,500 feet above the level of the sea. Brehmer himself remarked to me that he believed the altitude of Gorbersdorf (about 1,600 feet above the level of the sea) had much to do with his success. Dettweiler, on the other hand, deemed it of much less consequence than other factors. Observers like Solly, Fisk and Denison, in Colorado, are firm in their belief that the altitude of Colorado (over 6,000 feet) is one of the chief reasons of the benefit obtained by the life there, while Dr. Geddiugs, of Aiken, S. C., whose large experience makes his opinion of much weight, is evidently of the same opinion as Dettweiler. A discussion upon this point would be of great in- terest, but it is out of the limits of this paper, as I only wish to speak of the plan of establishing sanitaria for pulmonary diseases in the immediate vicinity of our great cities, in healthy localities, for the benefit of those who can not, or will not, for various reasons, seek more salubrious climates. The late Dr. Paul Kretschmar, of Brooklyn, N. Y., two or three years before his death, read papers be- fore the American Climatological Association, and before the local New York societies, strongly urging the establishment of such an institution in the hilly portion of New Jersey, near New York, but so far as 1 know, no active steps have been taken towards carrying out Dr. Kretschmar’s excellent idea. Very early in my practice I felt that some such in- stitution was needed near Boston, and as the idea grew stronger, I was enabled, with the assistance of Dr. Lovett, to establish, through the generosity of wealthy 5 people here and elsewhere, a small Sanitarium at Sharon, Mass., on the Providence Railroad, a region long known as one of the most healthy localities about here, on account of its gravelly porous soil, its abundance of woodland, and pure water-supply, my idea being to supply to people of very limited means a comfortable home where at the same time a constant medical supervision could be maintained. The institution was opened last February, and al- though it is, of course, much too early to give actual results, yet the evidences of the advantage of this method to that of sending patients hap hazard out into the country to board, are so strong, that I am already convinced that I was not wrong in my first belief that a properly regulated sanitarium would be of the great- est use in our community. A brief description of the sanitarium will be in place here. The place selected was a small farm on high land not far from the Sharon station, overlooking a charm- ing view towards the south and west. The soil is gravelly, very porous and dry, well-water not being found above twenty or thirty feet below the surface. Behind the house stretches from east to west a number of acres of woodland, chiefly of pine and hard-wood trees, which, with the line of the Moose hills, form an effective shelter from the harshest winter winds. On three sides of the house extends a broad piazza, in the centre of which, in a recess made on the southern front, the patients can be well protected, even in se- verely cold weather, when exercising or resting in the open air. The interior of the house is arranged to have as much sunshine and good ventilation as possi- ble ; open fireplaces are found in every room, and each patient has her own separate bedroom, no two ever sleeping in the same apartment. The walls are 6 all painted, and are frequently wiped with damp cloths ; the floors are of hard-wood covered with rugs, which are frequently cleansed, no laid carpets being allowed. The strictest rules are made as to the sputa of the patients. Cuspidors filled with damp sawdust are on the ground floor, and the contents are burned every day. In the bedrooms small paper cups in frames are at the bedside, and burned after use. When on the grounds the patients carry cloths placed in a rubber pouch in the pocket, the rags bring destroyed in the same manner, and the patients are forbidden to expectorate on the grounds or to use any other recep- tacle than those provided, every effort being made to insure the utmost cleanliness. The treatment usually pursued is first, that of giv- ing all the good nourishing food possible at the three daily meals, a lunch of milk or raw eggs being taken in the middle of the forenoon and afternoon. Accord- ing to the nature of the case, more or less exercise in the open air is taken, and daily rest in reclining chairs on the piazza, even in midwinter, when the sun shines, is one of the most important parts of the treatment, especially in haemorrhagic cases, in which much active exercise either on rising or level ground, is prohibited. In most of the cases, I have found the tri-weekly or daily use of the pneumatic cabinet to be of very marked benefit where expansion of the chest is needed, combining it oftentimes with some soothing vapor in cases where symptoms of bronchial irritation are marked. It is in such institutions that this instrument or other methods for expanding the chest and inhaling medicated vapors, can be used with the most beneficial effect, for the patient has the advantage of being near at hand, and can easily take the treatment as often as thought necessary. Judging by the effect in most 7 cases at the sanitarium I regard the pneumatic cabinet as one of the most valuable factors in the general treatment. Tonics are usually given ; stimulants occasionally when necessary, but drugs are avoided as far as possible. Everything is done to contribute to the mental welfare of the patients, and drives through the country and both out-door and in-door games are encouraged. The institution only receives women now, and only cases which are in the first stages of pulmonary dis- ease. We hope, as the project grows, to have cot- tages built adjoining the present house and to receive both sexes. The objection has been frequently raised by some, that the effect of putting many patients together is to increase the risks of possible infection, and that the effect upon the patient of seeing others ill about him, will be very depressing and hence deleterious. That both of these objections have a certain amount of truth in them no one can deny, but that practically, they amount to very little, to those who have had ex- perience in sanitaria, I am convinced. Before the Sharon Sanitarium was begun, I felt very strongly the force of the latter objection, and one of my first questions to Dr. Trudeau, when I visited his sanitarium at Saranac, N. Y., was, u Do not the patients become depressed by seeing each other ill ? ” In reply he said, “ Listen to that! ” and at that mo- ment the sound of some negro songs and very jolly laughter came from a group of patients on the piazza near by, and he added, “ That is the way it is all the time. Of course, there are times when each one feels depressed, especially at first, but they usually become accustomed to their surroundings, and if they improve, seem as happy as possible.” This was quite in keep- ing with the sentiments expressed at the large iusti- 8 tution at Gorbersdorf, by a young American lady who had been there for two years, when I asked her if she never felt depressed at being in a place where there were so many sick people. She laughed and said, ‘‘ Oh, for the first two weeks I came, I was homesick and of course I felt depressed, but I soon got over that and ceased to think of it, and I am so happy here now I hate to think of leaving, as Dr. Brehmer tells me I probably can in a few months ” ; and she told me that was the feeling with the majority. My own experience with the patients at Sharon only confirms this idea. They seem very happy ; and when de- pression comes I usually find it attributable to some outside cause and not to the proximity to other pa- tients. As to the possibility of infection ; with proper care 1 think this danger is reduced to a minimum. No one would deny that the ideal way would be for each patient to have his or her own establishment with a physician in constant attendance to regulate the daily mode of life in the most perfect climate to be found ; but as this method is unfortunately impossible for the large majority of sufferers, a less expensive course must be adopted, and my own belief is that the ad- vantages of the method of treatment I am advocat- ing so far outweigh its possible dangers that the latter practically fade into insignificance. Dr. S. E. Solly of Colorado Springs, in an admir- able paper entitled “ Comparative Results of Treatment of Phthisis by Climate,”2 gives the conclusions of several of the most celebrated authorities upon pulmon- ary diseases in Europe and America and by them gives a very convincing proof of the great advantages of treatment in closed resorts (sanitaria) as compared with that in open resorts. In Table III, entitled “ Comparison Between Open Resorts and Sanitariums 9 in Low Climates,’-’ he gives the following striking figures: Cases. Cured. Benefited, Open Kesorts in Low Climates, 1,724 t% 46% Sanitariums in Low Climates, 2,443 13% 274% First Stages of the Disease. Open Resorts in Low Climates, 685 5% 45% Sanitariums in Low Climates, 89 314% 45% All Stages of the Disease. In thus advocating the establishment of sanitaria in healthy towns near our large cities I do not wish it to be understood that I expect such results as are ob- tained in climates more salubrious and less trying than our own ; but I firmly believe and am daily becoming more convinced from results thus far obtained at Sharon that we can do infinitely more than heretofore to help a large class of patients who are unable for various reasons to seek other climates. Dr. Mason : I am sure that Dr. Bowditch’s sani- tarium will be of the greatest possible service, espe- cially when its scope is increased through larger means, so that more patients can be received, and when it can be made available for men. At present there is the greatest difficulty in Boston in haviuga male phthisical subject in the early stages taken care of for a long time. They come to our out-patient departments and wards for a few weeks and then disappear. They are not able to pay a large amount of money for their sup- port, therefore they generally go rapidly from bad to worse. The women have a better chance in small homes for that purpose. I do not think a large num- ber recover in the small city establishments. I hope the time will not be loug before Dr. Bowditch’s sani- tarium will be able to receive at least a few men such DISCUSSION. 10 as present themselves every week at our hospitals and have to be turned away without much hope of benefit. Dr. Osgood : One factor of Dr. Bowditch’s sani- tarium, which 1 am very glad has been opened, I wish to endorse strongly, and that is the separation of his patients. This plan recalls to me an interesting visit which 1 made ten or twelve years ago at the Hospital for Consumptives in Ventnor, Isle of Wight. For, at this institution, consumption was treated upon what was called, the “separate system.” At the time this hospital was opened the bacillus of consumption, of course, was unknown, and undoubtedly the separate plan of treatment adopted resulted simply from the observation of physicians, namely, that consumption, if not contagious, presented a good many strange coin- cidences in cases where persons who took care of the consumptives themselves were attacked by the disease. However that may be, the Ventnor plan, so far as I know, was in advance of any treatment of consumption that is in general use to-day, and I would like to ask Dr. Bowditch if his sanitarium is not the only one in the country in which patients are treated on the separ- ate system, which, of course, is the only one to be used in this disease. Dr. Bowditch : I cannot say positively. I know of Dr. Trudeau’s sanitarium at Saranac. He never has more than two patients in a room, and most of them have separate sleeping apartments. Dr. Osgood : In the Ventnor Hospital, by means of charitable donations, every patient, even the poorest, had his private room. I am quite able to sympathize with Dr. Bowditch’s new project, because, being connected with the Home for Incurables, I am fairly pestered by people who demand entrance for consumptives into the Home. Our regulations refuse admission to such cases. It seems to me there is no question as to the 11 great need of such retreats for consumptives among the poor and I hope Dr. Bowditch’s sanitarium will become rapidly enlarged. Dr. Knight : I think there can be no question in the mind of any one who has had to deal with pul- monary disease, tuberculosis particularly, that it is one that requires such constant care and supervision that it can be afforded much better in an institution than out of it, it being not the disease which has to be treated at present, but the condition of the patient, and the factors are so many which have to be regarded in improving the condition of the patient and enabling him to withstand the disease and bring about its ultimate arrest, that it is only the most constant care which brings about in the majority of cases the suc- cessful result, aud there is no question that the results are better in sanitaria than outside of them. Of course the sanitaria in health-resorts like Colorado are going to show better results as a rule. There are two in Colorado Springs aud it is fair to suppose that their results are going to be somewhat better at any rate than sanitaria in our own neighborhood, but the con- stant care which they get in the sanitaria here is going to be productive of excellent results. The first time that this subject was brought to my mind very forcibly that hospital treatment was good for consumption was when I was in Bellevue tempor- arily serving with the elder Flint. He said one day “ Did you ever notice how well these consumptives do in the hospital although our diet is poor and you would suppose in the crowded condition of our wards that they would not do particularly well, but you notice how well they are doing, and they are not hav- ing any medicine. You see what the regulation of their life will do for them.” This was true, so far that the majority of consumptives who came in in all 12 stages, improved from the judicious regulation of their diet and habits of life. Now it is perfectly well known that a patient will undo in one day’s over-exercise, all that you have done for him in six months. That is not likely to happen in the sanitarium, neither are they likely to be upset in the thousand and one ways that their relatives and friends at home offer them. That is one advantage, being free from the constant meddling and annoyance of friends. Then the association of patients with the same dis- ease curiously enough leads them to feel very differ- ently in regard to it. They talk over their symptoms, expectoration, consolidation and bacilli just as we talk about matters of medicine, with no more feeling really than we have. The other day when I was at Sharon, I was asked to drive down to the station with an attractive young lady. She had been discharged at the end of a week’s residence. She was supposed to have serious disease, but upon careful examination it was found that she did not have tubercular disease at all. I imagined she would rejoice at getting away from all those people, but, on the other hand, she was mourning that she could not stay. She said it was a delightful place and she would liked to have staid several months, so that the impression made on her mind in a week’s time was only a pleasant one. Dr. Bowditch, in closing, stated the present capac- ity of his sanitarium was for nine women. Incipient cases were especially desired, since they offered better prospects of cure. It was not a hospital. All the patients were up and about and able to take walks. They were not obliged to lie in bed unless something occurred which made it desirable to remain in bed for a day or two. There was no provision for free pa- tients at present. The price of board for each patient was five dollars per week. Two Volumes yearly, beginning with the first Nos. in January and July. But Subscriptions may begin at any time. This Journal has beerr published for more than sixty years as a weekly journal under its present title. Still it is incumbent upon this Journal, no less than upon others to assure its patrons from time to time, as the occasion arises, of its desire, ability, and determination to meet all the requirements of the most active medical journalism of the day, without sacrificing any of that enviable reputation which is an inheri- tance from the ivist. It is under the editorial Management of Dr. George B. Shattuck, assisted by a large staff of competent coadjutors. Communications from all quarters of the country are acceptable. Liberal arrangements are made for reprints of original articles, and for such illustrations as serve to increase their value or interest. All editorial communications, and books for review, should be addressed to the Editor. Subscriptions and advertisements received by the undersighed, to whom remittances should be sent by money-order, draft, or registered letter. Terms of Subscription : In the United States, and to Canada and Mexico, $5.00 a year in advance. To Foreign Countries embraced in the Universal Postal Union, $1.56 a year additional. Single numbers, 15c. Ten consecutive numbers free by mail on receipt of $1.00. Sample copies sent free on application. MedicalandSurgical Journal. Published by DAMRELL & UPHAM, A FIRST-CLASS WEEKLY MEDJCAL NEWSPAPER. PUBLISHED EVERY THURSDAY. THE BOSTON 383 Washington St., -Boston.