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CHAPTER VI.

THE ORIGIN AND GROWTH OF THE SANATORIUM TREATMENT OF PULMONARY TUBERCULOSIS IN MASSACHUSETTS.

Vincent Y. Bowditch, M.D.

THE SHARON SANATORIUM AT SHARON.

The Sharon Sanatorium in Sharon, was the first institution of its kind in New England to be established in accordance with the ideas of Brehmer and Dettweiler in Germany and later of Trudeau in the Adirondack Mountains in New York State. In certain particulars the sanatorium was for several years unique. Previous to its establishment in 1890 it had been thought necessary to place such institutions at a comparatively high altitude, at considerable distance from the sea, and in climates less subject than the coast of New England to sudden changes of temperature and humidity. The idea that patients could be successfully treated not far from home had hitherto been thought, if not absolutely impossible, at least of such doubtful nature that the suggestion was at first regarded by many as almost chimerical.

In spite of this skeptical attitude on the part of both the medical profession and the laity, and following the teachings of the late Henry Ingersoll Bowditch, who for many years had constantly taught the value of fresh air as the most important feature in the treatment of pulmonary disease, an appeal was made to private citizens of Boston, and the sum of about 130,000 was raised. The town of Sharon, approximately eighteen miles from Boston and ten miles from the seacoast, was selected on account of its favorable situation on the watershed between Boston and Providence, and because of its porous soil and abundant supply of excellent water. Through the bounty of a lady deeply interested in the plan, a small farm of twenty-three acres was bought, and upon a high knoll at an altitude of only about two hundred and fifty feet above sea level, sheltered by woods on the north, east and west, a commodious but simple building, suitable for nine patients and the administrative staff, was erected in the autumn of 1890. As necessary adjuncts to the sanatorium, a pumping engine and tank for the water supply were installed and a simple but thorough method of cesspool drainage was arranged, to be changed in later years to a perfected form of sewage filter-beds. The cost of these essentials for a sanatorium, in addition to a small amount of grading and road-making, amounted to about $20,000. The sum of $10,000 was therefore left for current expenses until the object and aims of the sanatorium should become generally known.

The institution was opened on the 9th of February, 1891, and the first patient was received on February 16. It was formally incorporated in March, 1891, with the legal title of the "Sharon Sanitarium." (1) The following directors and officers were elected: --

Board of Directors: Alfred Bowditch, President, N. H. Stone, Treasurer, Reginald Gray, L. Vernon Briggs, Miss Olivia Y. Bowditch, Miss Alice M. Curtis, Secretary, Miss M. H. Denny, Mrs. Horatio A. Lamb. Medical Directors: Vincent Y. Bowditch, M.D., Robert W. Lovett, M.D. Consulting Physicians: Henry I. Bowditch, M.D., (2) Frederick I. Knight, M.D. Assistant Physician, John J. Moran, M. D. Matron, Mrs. M. E. Small.

As the sanatorium was intended only for women in the early stages of tuberculosis, of very limited means, a uniform charge of $5 a week, exclusive of personal laundry, was established. This sum included all medical services, medicines and board. The same charge is still adhered to, in spite of the great increase in the cost of living in the past few years, and in spite of the fact that the annual deficit is much larger than formerly.

The Sanatorium has been dependent chiefly upon the public for its support, and in consequence of certain bequests has made notable additions to its buildings. In 1897 a small infirmary was built not far from the main building, for the reception of patients who should become very ill, or in case of an outbreak of any acute infectious disease requiring absolute isolation. In 1900, by the bequest of Thomas T. Wyman, a large wing was added, providing separate rooms for ten patients, attic rooms for the servants, a large treatment room, and a heating plant in the basement. Between this wing and the infirmary, and connected by a subway, a cottage with apartments for the matron-superintendent and for the resident physician was also added. The capacity for patients has thus been increased during the past few years to twenty-three beds.

During the past year extensive but simple alterations have been made. Sleeping balconies have been added to the main building and wing, so that every bed can be rolled out at night, the patients sleeping in the open air under a canvas canopy even in the coldest winter weather. The dining-room has been much enlarged, with marked increase of light and air by the insertion of a larger number of windows than before.

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To the small farm, upon which the buildings now stand, more than one hundred acres of beautiful woodland have been added to the property by gift and by purchase. By this the buildings are shielded from the harshest winds and the woods are being slowly developed as a park for the patients' use, the sale of timber being made a source of income to the sanatorium. A few acres of farm land are used for the production of vegetables sufficient for the patients' needs throughout the summer season, the supply of potatoes usually being sufficient for the whole year. Milk is obtained from an excellent herd of cows on the Town Farm near by, which is in charge of an excellent Superintendent, the animals being occasionally examined by the State Inspector.

The cost per patient is one of the difficult problems of such an institution. All sanatoria of this nature are naturally comparatively expensive. If good results are to be obtained, a much larger outlay is required for provisions than in ordinary hospitals. The fact that a prolonged stay is necessary for each patient means that the surroundings must be attractive, though not necessarily luxurious, and entertainment must be afforded to relieve monotony as essentials in treatment. The class of patients received at Sharon is also a factor in the expense. People of refinement, even if of very limited means, naturally require more than the lowest class of the poor. All these considerations have to be taken into account in estimating the comparative cost of different institutions. The price of board thus far charged ($5 a week) barely covers one-third of the outlay, and in spite of earnest endeavor to use economy it has hitherto been impossible to lessen the expense per capita.

The number of people in the working staff of the sanatorium is as follows: a Superintendent and Matron (since May, 1901, Miss Alice R. Hodges), who has charge of the general administration and of the nurses; a Resident Physician (Dr. Walter A. Griffin since 1901), who, with the Medical Director, has charge of the medical department; two nurses; seven maids; and two men-of-all-work for the stable and farm.

The experiment has been tried in times past of employing the patients in the general work of the household; but for various reasons this has been found impracticable, chiefly because not only is it apt to interfere with the course of treatment, but because of the liability to illness, thus crippling the management. Each patient, however, is supposed to have the care of her own room, unless the physical condition contraindicates it.

The institution is free of any debt, but is in constant need of funds to supply the annual deficit. An Auxiliary Committee of ladies and gentlemen has been of invaluable service in adding large sums to the treasury by bazaars and other entertainments. An attempt is being made to establish an endowment fund, and thus far about $20,000 has been obtained for that purpose.

The results obtained at Sharon have long since shown that what was started as an experiment over seventeen years ago has justified the belief that much more can be done near the patients' homes than was thought possible a comparatively few years ago. Since the development of the method of fresh-air treatment, by which the patients are practically in the open air nearly every minute of the twenty-four hours, summer and winter, the results are even more satisfactory than in the earlier days, when less rigorous methods were in use. A few statements are appended, showing the results of treatment.

The Medical Report for March, 1907, prepared in accordance with the plan used by the National Association for the Study and Prevention of Tuberculosis, gives the following results: out of forty proven cases of tuberculosis treated during the year, nineteen were discharged "apparently cured," nine were discharged "arrested," ten were discharged "improved," two were discharged "progressive."

In a paper entitled "Subsequent Histories of One Hundred and Sixty 'Arrested Cases' (3) of Pulmonary Tuberculosis treated at the Sharon Sanatorium, 1891-1906," by Vincent Y. Bowditch, M.D., and Walter A. Griffin, M.D., (4) the following facts are given: --

(4) Transactions American Climatological Association, 1907, printed in 1908.

Summary of the Total Number of "Arrested" Cases, 1891-1906 inclusive.

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It should be added that, of those who died, the majority were advanced cases in which arrest of the disease was not expected. Two, at least, died from some cause other than tuberculosis, and others returned against advice to unhygienic surroundings, and relapsed.

The present list (1908) of Directors and Officers of the Sanatorium is as follows: --

Board of Directors: Prof. William T. Sedgwick, President, N. H. Stone, Treasurer, 614 Sears Building, Boston, Mrs. Charles A. Porter, Secretary, Augustus Hemenway, Rev. Edmund F. Merriam, Arthur Dehon Hill, Mrs. Henry P. King, Mrs. Wm. T. Sedgwick, Vincent Y. Bowditch, M.D., Robert W. Lovett, M.D., L. Vernon Briggs, M.D. Medical Director, Vincent Y. Bowditch, M.D. Consulting Physician, Frederick I. Knight, M.D. Resident Physician, Walter A. Griffin, M.D. Superintendent and Matron, Miss Alice R. Hodges.

THE STATE SANATORIUM AT RUTLAND.

On June 5, 1895, pursuant to the provisions of chapter 503 of the statutes of 1895 of the Massachusetts Legislature, a bill was approved for the establishment of a so-called "Massachusetts Hospital for Consumptives and Tubercular Patients," and a Board of five Trustees was appointed by the Governor and Council. This is the first instance in America of the foundation of a state institution for the treatment of tuberculosis.

The sum of $150,000 was appropriated for the purpose of purchasing suitable land and for the erection of buildings thereupon.

The Board of Trustees, composed of Fred B. Percy, M.D., of Brookline, Alfred Worcester, M.D., of Waltham, and Messrs. John C. Hammond of Northampton, A. W. Esleeck of Holyoke and W. E. Parkhurst of Clinton, held their first meeting for organization on August 15, 1895.

After much individual study of the question, and after obtaining the opinion of many physicians throughout the State as to the best location for such a hospital, a farm of about two hundred acres in Rutland, in Worcester County, fifty miles from Boston, at an elevation of about eleven hundred feet, was purchased, as having many of the essentials for the location of such a hospital, and buildings, planned by the architect, W. Chester Chase of Boston, were erected.

In December, 1897, the first report of the Trustees was issued. It speaks of the unforeseen difficulties of drainage and of laying out a long road to reach the Sanatorium, both requiring a larger outlay than was at first supposed. The drainage was carried through a rocky cut to the west of the hospital to a point about one mile distant onto lands six acres in extent acquired for the purpose of filtration beds. At the time of opening, therefore, no administration building had been put up, owing to lack of sufficient funds, and in consequence, the Superintendent was obliged to occupy a portion of the hospital intended for other purposes. This left a capacity of about one hundred and seventy-five beds for men and women, instead of two hundred as originally intended. The price of board and treatment was fixed at 50 cents a day ($3.50 a week) . This price was not long afterwards raised to $4 a week, this being the present charge to all patients. At first no distinction was made as to race, creed or age, although there was a somewhat tacit agreement that no child under twelve should be admitted.

At this time the question was mooted of changing the name of the institution and of converting its purpose from that of a hospital for advanced cases to that of a sanatorium for the treatment of incipient and moderately advanced cases. In the Trustees' report for 1898, the success obtained at the Sharon Sanatorium was cited as an instance of what could be done for the successful treatment of incipient tuberculosis in Massachusetts, and the decision was made to so change the original purpose of the bill as to make the institution a sanatorium for hopeful cases, rather than a hospital for advanced cases. The wisdom of the Trustees in making this decision can only be fully estimated when one realizes the intense interest which was soon shown by other communities throughout the United States, who have since followed the example of Massachusetts in erecting state sanatoria.

Two specialists on pulmonary diseases were chosen to act as attending physicians, who should represent respectively the regular and the homoeopathic schools of medicine, in accordance with the terms of the original bill. Drs. Vincent Y. Bowditch and Herbert C. Clapp of Boston were selected to fill the positions. Their duties consisted in making weekly visits to Rutland; in taking full charge of the medical departments, with the privilege of having assistants who should reside in the hospital; and in making weekly examinations of applicants at the Boston office of the hospital.

On September 23, 1898, the hospital was formally opened by Governor Roger Wolcott. The first patient was received October 3, and Drs. Bowditch and Clapp began their service.

Dr. Walter J. Marcley had been previously chosen as Superintendent, and Miss Mary E. Thrasher as Matron. In 1900, by an act of Legislature (statutes 1900, chapter 192), the name of the hospital was changed to that of the "Massachusetts State Sanatorium" in accordance with the decision of the Trustees to exclude all far-advanced and hopeless cases from the institution.

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During the year 1901-02, at the suggestion of the State Board of Charity, five new buildings were added, -- an administration building, a recreation hall, a large dining-room and two new wards, -- thus increasing the capacity of the institution to two hundred and fifty beds. In consequence of the larger number of patients, a second medical assistant for the regular service was appointed at this time.

By statutes enacted in June, 1903, chapter 445, and under chapter 75 of Resolves of 1904, after a careful study of the question by the State Board of Charity, provision was made for the addition of "four brick cottages," two to be used as general wards, one as a possible "probation ward" and another as an "infirmary" for twenty or thirty patients who might require special nursing during severe illness. These wards were completed in 1905, with the exception of one spoken of as a "probation ward," which, owing to the unexpected expense of establishing a new heating plant, was omitted. The infirmary was finished later. The capacity was thus increased to about three hundred and eighty beds.

At this time, in 1905, the expense per capita was 18.83 per week, as against 19.36 in 1904.

In 1904 the Boston office was removed from 181 Tremont Street to the Out-Patient Department of the Massachusetts General Hospital, the duty of examining patients for admission falling upon the resident assistant physicians of the Sanatorium, instead of the attending physicians. Examining offices were also established in Worcester, Lowell, Springfield, Fall River and Pittsfield, special examiners having been appointed to these positions.

In 1905 two women members of the Board of Trustees were appointed, making the number seven in all.

In the same year, at the suggestion of the State Board of Charity, an out-patient department was established at the Sanatorium, for the benefit of patients who were boarding in the surrounding farm-houses but not connected with the Sanatorium. Two local physicians in Rutland kindly consented to take charge gratuitously of this department; but thus far, according to the Superintendent, in his eleventh annual report (1907), their services have not been in such demand as was at first thought would be the case, there being on an average only eight or ten calls weekly. Most of the work of this department now consists of laryngeal examinations and treatments done by the assistant physicians in the Sanatorium.

In 1906 the Trustees decided to change the form of administration by abolishing the positions of attending physicians, and by placing the whole medical department under the charge of a Medical Superintendent and his assistants. Following this decision, Dr. E. O. Otis of Boston (who had been chosen to fill the place of Dr. Bowditch after the latter's withdrawal on January I, 1906) and Dr. H. C. Clapp ceased to be attending physicians and were made consulting physicians, to serve without salary. Dr. Frederick L. Hills was also chosen as Medical Superintendent, in the place of Dr. Walter J. Marcley, who resigned to take charge of the Minnesota Sanatorium.

The cost per capita during this year again increased to $9.38, largely due, doubtless, to the general increased cost of living everywhere. In 1907 this cost was increased to $10.07, probably due to the same cause as before.

The report for 1904 contains an interesting statement as to the effect of the Sanatorium upon adjacent real estate values and upon the health of the native population of Rutland. On the assessor's books the total valuation of the town in 1904 was $704,183; in 1895, before the Sanatorium acquired any land, it was 1518,180, -- a gain of $186,000. The number of deaths from tuberculosis (exclusive of those who came to the town to be treated for the disease) for the whole time since patients were first received, viz., 1899 to 1904, inclusive, -- six years, -- was eight; for the six years immediately preceding (1893 to 1898 inclusive), eleven; for six years 1887 to 1892 inclusive, eleven; for six years 1881 to 1886 inclusive, fourteen. The town has thus averaged for the last twenty-four years two deaths per year from tuberculosis in a population averaging about one thousand. During the six years previous to 1904, with increased population, the deaths from this cause were less than before.

A table of comparative results expressed in percentages during the first eight years of the Sanatorium is hereby appended. It is taken from the tenth annual report of November 30, 1906.

Comparison of Percentages in the First, Second, Third, Fourth, Fifth, Sixth, Seventh and Eighth Years.

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Percentage of Incipient Cases "arrested" or "apparently cured."

A quotation from a study of the subsequent histories of patients who had left the Sanatorium, taken from the ninth annual report of September 30, 1905, is also added.

Subsequent Histories to Date (October 1, 1905) of Former Patients of Both Departments treated in the Sanatorium Previous to October 1, 1904.

The subsequent histories of former patients make the crucial test of any method of treatment, and are of vital importance.

For the first time in the history of the Sanatorium, tabulations of the results of former treatment have been made with painstaking care, and are hereby appended. That they give us convincing proof of the value of the work at Rutland in the past six years we think no one can deny.

In reading these figures, it must be remembered, moreover, that failure to receive replies or inability to trace the patient does not mean necessarily that the result has been unfavorable. In many of the earlier cases we have failed to receive news for months after the first inquiries have been made. Oftentimes, too, favorable accounts have been received of former patients through others. It is reasonable to suppose, therefore, that many of those from whom we have not heard as yet are still alive and at work.

The estimates for expenses during the ensuing year in the report of 1907 are as follows: --

The estimate for maintenance is made up as follows: --

THE MILLET SANATORIUM AT EAST BRIDGEWATER.

This sanatorium was founded and incorporated under the laws of Massachusetts in 1900, by Dr. Charles E. Millet of Brockton, Mass., and his two brothers, in memory of their father. Dr. Asa Millet of East Bridgewater, who for many years was a physician of that locality renowned for his unselfish devotion to others, his wonderfully good judgment, and willingness even in his advanced years to try new methods of treatment which appealed to his common sense.

His son, Dr. Charles E. Millet, conceived the idea of converting the old paternal estate into a sanatorium for tuberculous patients, in consequence of his success during the two years previous to opening the sanatorium in treating patients in their homes by making them sleep on open balconies. With the cordial consent of the brothers and the financial aid of the late Mrs. Abbie Wild Ford of Brockton, the estate was changed to a sanatorium, which was opened in 1900. The buildings are at an elevation of only one hundred and thirty feet above sea level, about twenty miles from the sea, and thirty miles to the south of Boston.

The original house was a fine old wooden structure, similar to many seen in that part of New England, built from one hundred to one hundred and fifty years ago. In the basement is installed a complete hydrotherapeutic establishment, which is used extensively in the treatment. In recent years additions have been made in the shape of a large two-story ward attached to the rear of the building, and especially adapted to open-air treatment by means of wheeling the patients' beds on to adjacent piazzas.

About 1901 it became necessary to build small "shacks" to accommodate the increased number of patients. It is believed that this was the first effort to bring the "shack" into use in this country. These "shacks" are near the main building, made of wood, twelve by eighteen feet, with flat roofs, mounted on posts six feet from the ground, and so arranged as to allow free passage of air on all sides. The interiors are divided into a bedroom twelve feet square and a dressing room six by twelve feet. In the latter is a chimney and stove, a set wash-basin with running water and water-closet, a movable bureau and a wardrobe.

The capacity has been increased from ten beds in 1900 to forty-five in 1908. The Sanatorium is heated by steam and lighted by electricity. There are separate buildings for nurses and servants. A private dairy farm of tested cows is a valuable adjunct to the institution, and the sewerage system has been perfected at heavy cost. The water supply is excellent and abundant.

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The method of treatment is such as is used in all similar institutions, with the inevitable differences of detail that must exist in different institutions. Special stress is laid upon hydro-therapy by Dr. Millet, who also advocates the use of as little medicine as possible. The Matron is a graduate nurse, and her assistants are members of the Training School in hydro-therapy, massage, practical and tuberculosis nursing, connected with the Sanatorium. Dr. Millet is the Physician-in-Charge, and makes daily visits to the Sanatorium. The institution is not a charitable one, although especially moderate charges are made to people of limited means.

Patients with incipient or moderately advanced disease are received; but it is not intended for far-advanced and hopeless cases.

The charges vary from $15 to $35 a week, according to size and location of the room or "shack." "Shacks" are from $25 to $35 a week, and rooms from $15 to $35. In the two wards, one for men and one for women, with five beds each, the price is $10 a week. This reduction in price is allowed in worthy cases after fullest investigation. The institution is not endowed. The cost per patient is, on an average, $15 per week.

Results, as stated by Dr. Millet, are: "About 33 1/3 per cent, of 'cures,' many advanced cases having been admitted."

OTHER PRIVATE INSTITUTIONS IN MASSACHUSETTS FOR THE TREATMENT OF CONSUMPTIVES.

The above-mentioned sanatoria are the largest in the State; but there are several small establishments, notably in the town of Rutland, under the charge of Dr. David P. Butler and Dr. George E. Derrick, who have had much experience in the treatment of tubercular disease. These establishments for the most part partake of the nature of boarding-houses. In some cases they are cared for by former patients of the Rutland Sanatorium, but are under the supervision of the above-mentioned physicians, who make weekly visits, the cost of which is included in the price of board. They help to fill a great need in our communities, for the care of the more advanced types of the disease. Numerous boarding-houses which receive cases refused by the State Sanatorium exist in the town of Rutland; but they have no official connection with any physician or with the Sanatorium.

An excellent small sanatorium for well-to-do patients was established at "Springside," Pittsfield, Mass., about two years ago, by Miss Mary E. Sullivan, who for eight years was head nurse in the men's ward at the State Sanatorium. A special staff of the best-known physicians of Pittsfield is connected with this establishment, but their services when wanted are not included in the price of board.

Of the great need of sanatoria, in the strict sense of the term, there can be no doubt in the minds of those who look carefully into the subject. The experience of those in charge of the Sharon Sanatorium alone would prove this. The number of applications there far exceeds the capacity of the institution, and many cases who would be greatly benefited by treatment are turned away from lack of room.

At the same time, the limitations of sanatorium treatment must be kept in mind. Those who have had the greatest experience know that it is only one of many methods to be employed in the attempt to check the enormous mortality from tuberculosis. Hospitals for the far-advanced cases, dispensaries, day and night camps, instruction and care in the homes, in fact, every method known to science must be brought to bear, and only by cordial and vigorous co-operation among the component parts can we expect to accomplish the desired result.