[Reprinted from Monthly Cyclopaedia of Practical Medicine, Vol. X, page 53, 1907.] THE SANATORIUM TREATMENT OF TUBERCULOSIS IN THE UNITED STATES AND EUROPE. By JOSEPH WALSH, M.D., PHILADELPHIA. President of the Pennsylvania Society for the Prevention of Tuberculosis, and Assistant Director of the Henry Phipps Institute. The next International Congress on Tuberculosis is to be held in Wash- ington, in September or October, 1908. It is expected that many of the Europeans interested in tuberculosis will attend, and it appears not untimely to compare the European sanatoria! methods of treatment with those in vogue in the United States. The papers and discussions of the last International Congress on Tuberculosis, held in Paris in October, 1905, at which there were over 3000 delegates from all parts of the world, revealed no new methods or specifics in the treatment of tuberculosis, and it was generally agreed that sufficient rest, sufficient fresh air. and sufficient good nourishment were the only elements in the treatment at present known to science. The general differences between the United States and Europe might be summed up to be first, the Europeans have been engaged a longer time in the work and have a greater number of hospitals, sanatoria, dispensaries, and soci- eties for the treatment and regulation; second, the enthusiasm of the Euro- peans has had time to wane somewhat in regard to sanatoria, but is very active in regard to new features, like dispensaries and antituberculosis societies. Although the general ideas as to rest, fresh air, and good nourishment prevail everywhere, details in the carrying out of these essentials differ some- what. In order to have some starting point from which to compare the different sanatoria, I will give the treatment in detail at the White Haven Sanatorium, with which I am connected, and endeavor to compare it with the treatment elsewhere. Rest.-On admission to the White Haven Sanatorium the patient is sent to the infirmary for two weeks in order to determine exactly his condition by frequent estimation of the temperature, etc,, and in order to avoid infec- tion of others in the sanatorium in case he has brought an acute infection 2 SANATORIUM TREATMENT OF TUBERCULOSIS. with him. If at the end of two weeks the patient still manifests a tempera- ture over ioo° F., or a very rapid pulse, he is kept there until these symp- toms subside. As soon as he leaves the infirmary and enters the general sanatorium, he is put on one hour's work a day. He does not leave the in- firmary, therefore, until it definitely appears that he is capable of doing this hour's work without harm to himself. The work is usually increased five minutes a day, and rarely ten minutes a day, until he reaches eight hours' work. He is kept at eight hours' work for one month, and then sent home with the idea that with proper care he can do eight hours' work a day at home. With signs of acute cold or any acute condition he is put on absolute rest, and if the period of rest is protracted his work is gradually increased again. Practically all the work about the sanatorium is done by the patients working in this fashion. It usually requires about six months to bring the patient to a point where he works eight hours a day for one month. In other words, we believe that absolute rest is a prime necessity when the patient shows acute symptoms or is badly run down; but since these patients are poor and must work when they leave the sanatorium, we believe it advisable to show them how to do it properly without injury to themselves. In the private sanatoria about White Haven where the visiting physi- cians to the White Haven Sanatorium send cases, the same ideas are carried out, though instead of work the patients are put on walking exercise. I do not know of any other sanatorium in the world in which the patients are put on such systematic exercise, except Brehmer's, in Gorbersdorf. Here they are put on graduated mountain-climbing from the day of admission. If the case is very acute, showing high temperature, rapid pulse, or extreme debility, of course it is put to bed even in Brehmer's Sanatorium, but it is probable that they start exercise, and in the form of mountain-climbing, much earlier than in any other sanatorium in the world. In the majority of other sanatoria in the world which I have personally visited comparatively little insistence is placed on exercise. In Rompler's Sanatorium at Gorbersdorf, in Falkenstein, and in many others patients remain on rest during their entire stay, even though they remain a year. It appears to me that practically the same theoretical ideas relative to rest and exercise prevail everywhere, but in the majority of cases it is only the rest that is insisted on. In Frimley Sanatorium, which is practically the country branch of Brompton Hospital, London, which receives the same class of patients as the White Haven Sanatorium, they endeavor to have the patients do a certain amount of light work, like gardening, etc., but I understood, without great SANATORIUM TREATMENT OF TUBERCULOSIS. 3 success. They claim that the class of patients coming there, many of them clerks in London counting-houses, think it infra dig. to work in a sanatorium, and would rather leave than work. This seemed to be the view in the public sanatoria throughout Europe generally, like, for instance, in Bournemouth and Beelitz. I think the same is true also of the majority of the public sana- toria in the United States. In the private sanatoria in Europe, like Falkenstein, Hohenhonnef, and Rompler's, patients are sometimes found playing light games like croquet, but scarcely anything more violent than this. In other words, in sanatoria generally, rest is not only believed to be an essential, but exercise is, as a rule, so relegated to the background that it is scarcely in evidence. Fresh Air.-In the White Haven Sanatorium all the windows in the rooms or wards are kept wide open at night; while on rest the patients sit outside ten hours a day, and while on work are outside at least all the hours that they are not working. This is recognized as the theoretical ideal every- where, and I think it is faithfully carried out in the United States and Eng- land. It did not strike me that it was quite so thoroughly carried out on the continent. Though this idea was put before the patients, it was not abso- lutely insisted on, and especially in the private sanatoria considerable leeway appeared to be allowed. In Falkenstein, in Rompler's and in Brehmer's, though the patients were urged to remain outside in the day time, the most beautiful reception rooms, reading rooms, libraries, and closed winter gardens furnished practical in- ducements to remain in-doors. Moreover, in every room there were double windows and the patients apparently exercised their own control of them. Good Nourishment.-The nourishment at the White Haven Sanatorium consists of one square meal of solid food in the middle of the day, and three quarts of milk and six raw eggs over the rest of the day. Shortly before the patient goes home some additions are made to this diet. I do not know of any place in the United States where exactly this same diet is followed, though I believe a similar diet is followed out at Nordrach, in Germany. In Europe generally they insist on forced feeding, but allow a much wider latitude in the articles of food. In practically all the sanatoria in Europe which I visited they furnish three solid meals a day, and three light lunches. These light lunches usually consisted of milk and raw eggs. The articles of diet at the solid meals were those common to the country; for instance, in Germany I have seen not infrequently coffee and rolls for breakfast, ham and sour kraut for dinner, and cold beef or sausage and always cheese for supper. 4 SANATORIUM TREATMENT OF TUBERCULOSIS. Alcohol.-In the White Haven Sanatorium alcohol is never used unless in an acute case of pneumonia. I think this is the usual routine throughout the sanatoria in the United States. The same is true of the public sana- toria throughout Europe. In the private sanatoria in Europe, however, when the patient can afford to pay for it he is allowed in England ale or porter for dinner, and in Germany wine or beer. In Germany they also allow wine or beer at the evening meal if it is desired. Tuberculin.-Exactly as in this country, in some sanatoria in Europe tuberculin is used freely, in others not at all. It is probable that the best and most conservative recent article on the use of tuberculin for treatment has emanated from the United States and was read at the last meeting of the National Association for the Study and Prevention of Tuberculosis, by Drs. Trudeau and Brown, of Saranac Lake. Inhalations.-Many of the sanatoria in Europe show handsome and splendidly equipped inhalation-rooms. On inquiry in the private sanatoria I found that creosote was the most common medicament inhaled. I asked if they thought that they derived any benefit from it, and they answered they did not, except whatever mental impression it exerted on the patient. In the public sanatoria, like Beelitz, these inhalation-rooms are not used at all. Inhalation-rooms are rare in the sanatoria in the United States, and inhala- tions, when used, are practically restricted to laryngeal cases. Douches.-At the White Haven Sanatorium patients are advised to take a complete bath twice a week, and since the shower bath is the most sanitary in a large institution, it is in the form of a shower that the bath is taken. They are advised also to sponge their chest and back each morning with cool water. When Brehmer founded his sanatorium he advocated douches every day. This idea was consistent with his general ideas in regard to exercise. Though Brehmer is dead, his ideas in regard to exercise as well as the douche continue to be religiously carried out. The douche-room in Brehmer's is an ordinary room in the basement, with an extremely strong douche falling from a distance of about twelve feet above the patient's head. The douche is manipulated from a room absolutely separate and unconnected with the douche-room, and with the patient's chart before him the physician regulates the strength and duration of the douche. In many of the sanatoria, both private and public, on the continent, elab- orate douche-rooms are found. The douche-rooms at Falkenstein, at Hohen- honnef, and at Rompler's fell into disuse years ago, yet the majority of recent public sanatoria in Germany have installed the most elaborate rooms I have ever seen though, I understood, they are rarely, if ever, used. SANATORIUM TREATMENT OF TUBERCULOSIS. 5 Climate and Altitude.-In Europe there is practically no insistence on altitude or climate. The recent sanatoria over the continent are at various degrees of elevation and the handsomest and most elaborate are not elevated at all, at least not more than will afford them a free sweep of the country, more on account of the view than for any other reason.' Sea-coast, too, appears to make no difference in their minds. The older English sanatoria, like Ventnor and Bournemouth, are on the sea-coast, the more recent ones in the country near the large cities. In France, where the adult sanatoria are all recent, the great majority are on the sea-coast. In Germany, they have taken no pains but to put them near the large cities, the handsomest ones that I saw, namely, Buch, Belzig, and Beelitz, being built on the level, without view of any kind (except that of their own landscape gardening), just outside of Berlin. Treatment of Cough.-In the White Haven Sanatorium our experience shows that the proper amount of fresh air, rest, and light nourishment stops the cough, at least to the extent that it is no longer annoying to the patient or to others. We believe that although opium may stop the cough for a night, its constitutional effect, especially the effect on digestion, is very bad, and the state of the patient is usually worse after the use of opium than before. Our general rule, is, therefore, not to give opium in any form nor under any circumstances. The only exception which we are willing to grant is in a condition of considerable nervous excitement following a severe haemorrhage, when one single hypodermic injection of morphine is given in order to relieve the excitement. I myself am so imbued with this idea that I can scarcely believe an institution is doing good work when I find the pharmacy over- stocked with preparations of opium in all its forms. Yet in Europe heroin and codeine appear to be used rather liberally, especially in private sanatoria. Directors in sanatoria and resident physicians to whom I talked not infrequently claimed that aggravated cough could be relieved by no other means. I believe this is proven false, however, by the comparatively little use of opium in all our American sanatoria and its prac- tical disuse in the White Haven Sanatorium. Pleurisy.-The ordinary treatment for pleurisy all over the world is strapping in severe cases or cases with effusion; painting with iodine in chronic cases, or, if this does not relieve, a blister. In Belzig Sanatorium they were using for acute pleurisy and acute bronchitis the wet chest pack. This consisted in a wet bandage (wet with water) wrapped around the entire chest from the shoulders to the margin of the ribs, covered with another 6 SANATORIUM TREATMENT OF TUBERCULOSIS. bandage, and this in turn by wax-paper or oil-silk, and changed every six hours and in special cases every three hours. Sanatoria.-In regard to the sanatoria themselves, the principal differ- ence between the United States and Europe is that the Europeans have been a longer time engaged in the work and have a greater number of them. Moreover, the European sanatoria are much more elaborate and better fitted out. The private sanatoria are large, massive, and handsome, but the public sanatoria are practically indescribable in their magnificence. Although they have a larger number of sanatoria than we have in the United States, and are able to treat more patients in the course of the year, yet I believe we accomplish better individual results. On the continent there is some excuse for the magnificence of the sanatoria, as they are superbly maintained, being supported usually by popular insurance companies. In England, however, they lack maintenance to a greater degree than we do in the United States, and as a consequence the amount of money put into the building seems ex- cessive. In this country the general idea of building and maintenance follows those in vogue at Saranac Lake and White Haven. Saranac Lake Sanatorium was begun with one patient in a shack, White Haven Sana- torium with three patients in a barn, the buildings progressing as the number of patients increased. As examples of European sanatoria we may mention the King's Sana- torium at Midhurst, in England, and Beelitz Sanatorium, just outside of Berlin. The King's Sanatorium has now been building for four years and is not yet completed. It will cost when finished $1,000,000. It was built after the elaborate plans of Arthur Latham, of England. It is built in a sort of Y-shape, the administration part being the lower leg of the Y. Despite the amount of money that is being put in the King's, Northwood, Frimley and Pinewood, which are not far away from it and are elaborate modern sana- toria, have only half their quota of patients. Northwood has accommodation for 120 and has about 68, with Frimley and Pinewood in the same plight. The reason for this is not that they have not sufficient patients to fill these sanatoria, but they have not sufficient maintenance to run them. The sanatorium at Beelitz is so complete that it is doubtful if any sana- torium will ever be built to surpass it. It cost over $3,000,000. It has 600 beds; 300 for tuberculosis and 300 for general constitutional diseases like chronic rheumatism, nervous diseases, etc. The two departments are quite widely separated from each other, and the males and females are also sepa- rated in each department. The details of the equipment at Beelitz that are SANATORIUM TREATMENT OF TUBERCULOSIS. 7 out of the common would necessitate an article in themselves. Not a few of these elaborate details are superfluous, yet there is an excuse for Beelitz which does not exist for the elaborate sanatoria elsewhere, especially in England. In the first place, all the public sanatoria in Germany are magni- ficently supported and there is no feeling that more money should be put into the maintenance; second, Beelitz Sanatorium itself was built by the People's Insurance Company, which found itself in a position where a certain amount of surplus had to be gotten rid of or it would probably go elsewhere.