Died: August 12, 2003
Married: Janet Parker
Dr. Alfred Mills "Fritz" Decker was born in Clarkson, New York, in 1918. In 1935, after graduating from Brockport High School, Decker attended the University of Rochester initially majoring in chemistry, but changing his course of study to medicine at the start of his sophomore year. Decker received his bachelor's degree with Phi Beta Kappa honors in 1940, and his medical degree with Alpha Omega Alpha honors in 1943.
Decker's father and grandfather cured in Saranac Lake, and as a child, he spent two weeks in the region each summer.
He married the former Janet Parker, also a University of Rochester student, in Lowville on December 20, 1943. He then completed a residency at Barnes Hospital in St. Louis, Missouri.
In April 1946, Decker enlisted in the U.S. Army, serving in Italy. Upon his return, he spent twenty months as a chief of surgery and a consultant in general surgery, and was made a captain. He was discharged in December, 1947. Returning to Barnes for more training, he took a one-year fellowship at the Royal Victoria Hospital in Montreal, Quebec, followed by a one-year surgical fellowship at the Wheeling Clinic in Wheeling, West Virginia.
In July 1951, Decker was named chief of surgery at Sunmount Veteran's Administration Hospital in Tupper Lake. In early 1954, he took a teaching appointment at the Medical College of Virginia, but returned to Sunmount in 1955. In 1957, Decker began private practice in Saranac Lake, working six days a week as a surgeon at the Saranac Lake General Hospital, Tupper Lake General Hospital and Lake Placid Memorial Hospital. He estimated that he drove 24,000 miles each year between the three villages.
He chaired the hospital's 75th Anniversary Challenge, a fund-raising campaign that raised $1.3 million to expand the hospital's facilities. In 1989, the hospital dedicated its new surgical wing in his honor. In 2001, he was named honorary chairman of the Adirondack Medical Center for the 21st Century campaign.
In 1992, he retired from practice, but remained active at AMC. He was active in the community, both during his practice and after his retirement. He served on the boards of the Trudeau Institute, St. Joseph's Rehabilitation Center and High Peaks Hospice.
He was also an active academic physician, and throughout his career, was published frequently in various medical journals.
At the time of his death, Decker's friends around the area remembered his wry wit, his devotion to his family and his love for the Adirondack region. "The passing of Dr. Decker leaves a huge void at Adirondack Medical Center," said the executive director of the hospital's foundation. "His superb medical and surgical skills were only surpassed by the extraordinary man he was."
- Forbes, Ed and Bob Seidenstein, Adirondack Daily Enterprise, August 23, 2003
This undated speech by Dr. Decker is courtesy of Janet Dudones
Dr. Martelo, members of the Warren County Medical Society, I thank you for the privilege of addressing you on the subject of the treatment of tuberculosis in Saranac Lake. What I am going to recount is a mix of 50% of what was done in Saranac Lake, 25% of the contributions of Sunmount VAH and this, against the background of 25% of what was going on in the nation "and the world. As a listing of developments and facts, I am afraid this can't be nearly as exciting to you as it was to us, especially in the late 1940s and early 50s. It is important to remember that in the 1870s when this story commences the annual death rate from tuberculosis approached 200/100,000, one of every 3 deaths was from tuberculosis, the Number 1 killer. A diagnosis of consumption was considered a sentence of death.
Tuberculosis built and sustained the village of Saranac Lake from 1875 to 1954. No discussion of tuberculosis in Saranac Lake or in the USA should begin without, an understanding of the life & work of E.L.Trudeau. Born in 1848 into a family of comfortable private means he attended P&S Medical School in New York City and graduated in 1871. From September of 1870, he had lovingly nursed his brother, Ned, who died of galloping consumption in December of that year.
Upon graduation from P&S in June of 1671, Dr. Trudeau married and at the end of a protracted European honeymoon, he became ill with tuberculosis of the cervical lymph glands. Despite this he commenced developing a New York City practice, but in 1873 a colleague diagnosed pulmonary tuberculosis. Early that summer he went to Paul Smiths Resort Hotel about 15 miles from the present village of Saranac Lake. There, hunting, fishing and resting he improved so greatly he returned to New York City in late fall. Thereafter he spent most summers at Paul Smiths, hunting and fishing
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Lake and in 1885 Little Red, a one-room cottage, was built for $400 on the side of Mt. Pisgah in Saranac Lake and housed 2 factory girls from New York City. From that time through the 1930s, the cottages, infirmary, administrative buildings, staff housing, laboratory, X-ray and occupational therapy buildings were gradually added as funds were raised. This was the Adirondack Cottage Sanitarium, known after Dr. Trudeau's death as the Trudeau Sanatorium. Early on old women and guides did the nursing. As the San developed and as its reputation grew, more and more young physicians and nurses with tuberculosis "cured" there and became caretakers as they were rehabilitated. Many spent the rest of their lives practicing locally and many more scattered over the whole country as tuberculosis specialists. The School of Nursing was opened and nursing schools statewide rotated their students here to learn tuberculosis nursing.
In 1887 Dr. Trudeau presented at a meeting in Baltimore his "rabbit island" experiment. 5 rabbits were inoculated with tuberculosis bacilli and freed with plenty of food on an isolated island near Dr. Trudeau's summer camp. 5 others were inoculated, placed in cramped dark quarters with scant food. 5 controls were placed in similar unfavorable conditions without being inoculated. At summer's end, only one of the 5 island rabbits showed any tuberculosis and that one appeared to be handling it well. All 5 inoculated rabbits in the cramped unfavorable environment died of the disease, while the uninoculated controls, though thin and scruffy, showed no tuberculosis. On this great science, well-received, developed the sanatorium system of Trudeau, the United States and Canada. By 1935 there were 471 sanatoria and 418 tuberculosis sections in large hospitals in the USA. There were 1300 private patients in "cure cottages" in Saranac Lake in addition to those in the Trudeau, Ray Brook State, Gabriels, Will Sogers, Stonywold, and Sunmount sanatoria.
Treatment was pretty well standardized on the Trudeau model and consisted primarily of relief of responsibility, rest, good food, fresh air and a steadily increasing dependence on varying forms of collapse therapy. Collapse measures were based on the knowledge at Trudeau that the tubercle bacillus reproduced 5 times faster in an aerobic environment, that is, in cavitary disease.
In 1886 Forlanini in Italy had introduced pneumothorax as a means of putting diseased lungs at rest, allowing cavities to collapse and to some degree excluding oxygen from the disease. This technique was ultimately endorsed by the International Tuberculosis Congress in Rome in 1912 and by 1937, 50-80 of sanatorium patients were receiving pneumothorax. In Saranac Lake and elsewhere thoracoscopy with lysis of adhesions to permit adequate collapse was commonly done. Refills were accomplished about every 2 weeks using fluoroscopy with homemade pressure and volume controls. Tuberculous empyema requiring at first closed and ultimately open drainage was a too common complication.
Pneumo-peritoneum with or without associated unilateral crushing or avulsion of the phrenic nerve to collapse mid and lower lung field cavities was based on the sound observation that cavities in these areas frequently closed during pregnancy only to reopen after delivery.
In Germany, Brauer, Wilms and Sauerbruch developed collapse therapy by surgically removing ribs overlying upper lung cavitation — thoracoplasty. This was quickly picked up and refined in this country. Dr. John Alexander of the U. of Michigan wrote his definitive book on collapse therapy of all kinds while lying on his back in the Trudeau Sanatorium with his paper supported over him.
In 1926, after reading Alexander's book, Norman Bethune, then a Trudeau patient, too restless for bed rest, stormed into a Trudeau staff meeting demanding collapse by pneumothorax, when a staff member suggested that there were risks involved in the treatment, Bethune threw open his shirt, grinning, and exclaimed: "Gentlemen, I welcome the risk!" Within 2 months, his cavities closed, he was discharged. Within a decade he had distinguished himself on the battlefields of Spain where he introduced direct blood transfusion and finally in China as surgeon to Mao's army, dying not of tuberculosis but of septicemia from a cut incurred draining an abscess.
Intestinal tuberculosis was treated by a tablespoon of cod liver oil in tomato juice daily, cold abscesses by drainage, and joint and spine disease by fusion. I was always amazed that long splints cut from the tibia and laid on lamina bared of periosteum and bathed in tuberculous pus could produce a solid fusion. Tuberculous peritonitis presenting as an odd acute abdomen cleared promptly after mere exposure during exploratory laparotomy.
Sporadic attempts at resection of diseased lung in the 1930s or early 1940s were rarely successful being plagued by often fatal tubercular complications of spread, fistula, empyema — often all of these.
Earlier Dr. Trudeau and the Trudeau staff had quickly learned that success of the rest, air and food treatment was rare with advanced disease though quite dependable with so-called minimal or even moderately advanced disease and that success could be greatly enhanced if cavities closed. Accordingly the Trudeau Sanatorium tried to admit only favorable cases. Since early diagnosis was more common among medical students, doctors and nurses, a great many young medical people cured at Trudeau. As they improved they worked with other patients, apprenticed with local doctors or helped in the bacteriology, physiology or other laboratories. This led to considerable expansion in research locally as well as a great broadening of their familiarity with the unique properties of the disease. The development of medical-surgical conferences for decisions in guidance of a high proportion of the cases was another educational plus as was the annual two-week long Trudeau School, attended by physicians from all over this country and the world. The result was that these generally young physicians, once cured, were able to spread all over the country and become the local or academic specialists in tuberculosis and, secondarily, in other lung ailments, for the Trudeau Laboratory was also a pioneer in studies of pneumoconiosis.
Starting with Koch himself, searches for a specific anti-tuberculosis medication became increasingly common and sophisticated- Koch's experiments with a glycerin extract of cultures of the bacillus known now as tuberculin were primitive and unsuccessful. The enhancement of immune response with this agent is to this day being evaluated and to some degree utilized in oncology. Dr. Trudeau used it widely for tuberculosis for a time but without clear success.
In 1919 an attenuated strain of tubercle bacilli was developed and named BCG after the initials of its originators with the idea it could be used as a vaccine. Early successes were smothered by a disaster in 1930 in Lubeck, Germany when 249 babies were inoculated with a virulent culture by mistake. Subsequent studies and use by the WHO have shown consistent success in preventing the problems of primary tuberculosis in bone, meninges, joints, liver and spleen, but very inconclusive findings in preventing or controlling typical secondary tuberculosis of the lungs. During his tenure as the last medical director of the Trudeau Sanatorium Dr. Gordon Meade offered and encouraged BCG vaccination of Saranac Lake school children. Currently it is used only in high exposure situations in this country where early diagnosis and effective drug therapy are widely available. In many 3rd World countries, however, it would seem to still have a great deal to offer.
In Saranac Lake the population, 300 in 1880, had swelled to 8,020 in 1930. There were 13 drug stores, 53 private medical doctors, 5 undertakers, 4 hotels, 7 churches and 19 taxi services. (Of some interest the son of a taxi driver who was an arrested case of tuberculosis became the head of Nat'l Semi-Conductor.) The total occupation of the village dealt with the care of tuberculosis. Patients arrived by train from all over the country and world. After an evaluation at a Reception Hospital they were apportioned to specific physicians and sanatoria or private cure cottages. Doctors were to a degree rated by how well they could maintain disciplines of rest and behavior. After months or years total bed rest might be lightened as there were signs of improvement to permit major bathroom privileges. If arrest of the disease seemed progressing, gradually increasing activity was permitted, 3 large meals with 2 or 3 between-meal supplements were encouraged. Beds or cure chairs were outdoors on sleeping porches even in very cold weather and patients were carefully taught how to bundle up. Temperatures were taken 2 or 3 times daily and weights recorded weekly. Much privilege depended on favorable charts. Portable X-rays were taken, and sputum or gastric washings examined for so-called Gaffkey counts of acid fast bacilli as the physician felt indicated.
Deterioration or presence of significant cavitation might lead to a decision for some type of collapse with or without a hospital stay. The Saranac Lake General Hospital was built in 1914 and a sophistication in the field of surgical collapse quickly developed. This included thoracoscopy, intra- and extra-pleural pneumothorax, plombage with oil and later, plastic balls or rings, phrenic nerve crushes or avulsions, classical thoracoplasty and ultimately resection, within the sanatoria, transfers from cottage to infirmary or vice versa reflected the course of the disease.
This "cure life" persisted from the late 20s through the early 40s. Bed rest was taken very seriously. Dr. Kinghorn was outstanding for his control. One young woman he admitted, he did not see again for a year and when she spied him in the hall she called out, "Dr. Kinghorn, can't I start to get up now?" His reply: "You stay right there and I'll discuss it with you next year!" Tales of the rigors of cure porch life include this, from a friend of ours- "For our feet, we had warmers of cast iron full of hot water. I always wore heavy socks to bed and one night my iron pig, as we called them, leaked and my socks froze to it. Waking in the morning, unable to move my feet, I was convinced I was paralyzed."
Many famous physicians cured at Trudeau. Of these, Dr. Blalock was outstanding. As he put it, "I cured 5 days for tuberculosis, sneaked into the village Saturday night to forget the cure, and cured Sunday to recover from Saturday night."
By 1944 the annual death rate from tuberculosis had declined to 47/100,000. This may have been the combined results of sanatorium care and widespread public education as to the infectiousness of the disease and desirability of good living habits.
In 1943 Waksman reported effectiveness of a fungal extract against the tubercle bacillus, beating out scientists all over the world who were following the lead of Florey and Fleming with penicillin. This agent, streptomycin, was tested clinically at the Mayo Clinic in 1944 and hailed as a miracle drug. Tests followed at Trudeau as well as at many other centers. All patients improved, but it quickly became apparent that those with significant cavitary disease persisted sputum positive and commenced to relapse after 4 months. Continued or retreatment proved futile and the phenomenon of drug resistance was recognized. Techniques for recognizing and quantitating resistance were developed in Saranac Lake by Bill Steenken, a self-taught bacteriologist who one day would receive an honorary doctorate for his work. Waksman received the Nobel prize in Medicine for his contribution. The Trudeau Laboratory became the international certifying center for laboratories testing resistance to anti-tuberculosis drugs in the later 40s and early 50s. Therapy conferences here and throughout the nation were marked by pleas of surgeons to be allowed to do their procedures of collapse or, increasingly, resection of diseased lung tissue during the effective early 4 months of the streptomycin therapy. Medical men tended to hope to control the disease without surgery.
In 1944 Swedish researchers found that para-amino salicylic acid was effective against the disease. It quickly became apparent that it was not as good as streptomycin and was also plagued by the development of resistance after about 4 months.
At Sunmount VAH, a tuberculosis center close to Saranac Lake and sharing consultants, two new concepts were being evaluated. One was presented by Dr. Edgar Medlar, their pathologist, who had demonstrated in autopsy material that the "scars" seen in x-rays of arrested cases were really caseous deposits which contained acid fast bacilli and had a persisting communication with the bronchial system. Spillage from these foci he postulated "spread" the disease and accounted for its relapsing nature even with minimal residue. He urged resection of these lesions in their quiescent phase. The second concept was to test using both streptomycin and PAS together hoping to delay the development of resistance. This was based on the idea that production of a mutant resistant to both drugs would be delayed. The exciting result was that disease of all but that with the largest cavities became sputum negative by 4 months of treatment. Dr. Medlar urged resection of residual disease at this stage and indeed when resected the caseous residua were found to contain acid fast bacilli and to communicate with the bronchial system. This work was presented in May of 1950 before the American Association of Thoracic Surgery. I heard this presentation and was so stimulated by it that I promptly moved to Sunmount and became one of their surgeons. Thereafter the technique of wedge and segmental resection of residual disease when it became sputum negative on combined Sm and PAS therapy was widely practiced at Sunmount and Saranac Lake and quickly picked up by chest surgeons all over the country. Efforts to get these antibiotic treated and resected bacilli to grow in culture or cause disease in guinea pigs failed, and we gradually realized they were dead. This finding was coupled with the observation that patients who had converted their sputa on combined Sm and PAS therapy and had been treated 8-12 months, but who declined surgery, did not relapse. It should be noted that at Sunmount we evaluated treatment by only 2 criteria: conversion of the sputum to negative and occurrence of relapse. This was a great change from measuring cavity or lung shadow size in millimeters and quantitating still positive sputa which along with weight gain and fever level had been used CO evaluate treatments previously.
Some large and thick-walled cavities did resist Sm and PAS treatment and produce resistant organisms. However, we were just working out coordinating adjunctive surgical measures of collapse or resection to rid the lung of these predictors of failure when, in 1951, along came INH. INH had been known chemically since 1912 but was only tested against tuberculosis in the late 1940s. It proved even more effective than Sm and was easily administered orally. It lacked 8th nerve toxicity and actually demonstrated only very rare intolerance. Given alone in the presence of significant cavitary disease, it, too, was limited by the development of resistance and so was tested in many regimens throughout the VA system as well as in many other treatment centers including Saranac Lake. Several things became apparent. One, though widely used especially for "galloping consumption", triple drug therapy had little if any advantage over two-drug regimens. Two, in the absence of cavitary disease single drug INH programs maintained 8-12 months yielded lasting cures. Three, in patients without persisting cavities or with small thin-walled cavities who converted their sputum promptly on a combined regimen, the bacilli found in resected lesions were dead and did not need to be removed. Four, in far-advanced cavitary disease daily administration of two drugs was superior to the use of a regimen administering Sm every other day. And five, sanatorium regimens of bed rest were unnecessary except perhaps for the sickest patients and to limit spread of the disease to others during the early months 01 treatment.
The effective care of tuberculosis with little or no confinement became widely disseminated and the tuberculosis industry in Saranac Lake dissipated rapidly. In 1954 the Trudeau Sanatorium closed. The Trudeau laboratory continued some of its bacterioloqic work and its work with industry on pneumoconioses. After 1954 the Laboratory's endowment, untouched, grew from 3 million to 5 million and in  its Board of Directors guided by E.L. Trudeau's grandson, Frank, established what has become the Trudeau Institute, devoting its efforts to immuno-biology. It did continue to maintain the world bank of tuberculosis cultures. Research without teaching responsibilities has proven very efficient and the work of the Institute has received world-wide recognition, thus maintaining a medical research tradition in Saranac Lake.
By 1967 the annual death rate from tuberculosis was 4/100,000. At about that time two significant episodes were noted. The son of Mr. Steenken, Saranac Lake's bacteriologist, being treated with cortisone for lymphatic leukemia died of unrecognized miliary tuberculosis. At almost the same time in Hyde Park, Mrs. Franklin D. Roosevelt, also receiving cortisone therapy, died mysteriously of what proved to be overwhelming but unrecognized tuberculosis. Thus was ushered in the era of tuberculosis in the immuno- suppressed. That is a story for another day.