Monday, October 24, 2011


Peter Warren : The Evolution of the Sanatorium (extract )

The priority of all sanatoria was to expose the consumptive to the
maximum degree of fresh air. Balconies were a common feature on
which the patients spent the day.87 Trudeau put the value of fresh natural
air to the test with a renowned experiment in which he took rabbits
inoculated with tubercle bacilli. Four of five confined to a damp, dark cellar
died compared to only one of five living in the cold outside air.88
Good nutrition was the second emphasis. The patients received abundant
food with up to seven meals a day. Plenty of milk and fats with
strong wines and spirits were given. The patient’s weight was used as
one indicator of progress.89 Cod liver oil was much favoured.90
Rest and exercise was a major consideration in the sanatoria. Brehmer
and his pupil Walther believed exercise was more important, while Dettweiler
and Trudeau concluded rest was more beneficial. At first Brehmer
was vague about what he meant by exercise. At Görsberdorf he built
paths up the mountains for patients to follow but, realizing that consumptives
were easily exhausted, provided benches for frequent rests. At
Nordrach the regimen also emphasized exercise principally for rehabilitation
after recovery.91 At one extreme Marcus Paterson at Frimley gave
patients construction projects, and, influenced by the work of Almroth
Wright, decided that such exercise cured tuberculosis through what he
called auto-inoculation.92
However the majority of physicians felt that exercise in active tuberculosis,
as revealed by fever, weight loss and spitting blood, was harmful.
Dettweiler encouraged patients to rest outside in a reclining position. He
was unsure if this was possible in winter but after trying it with intelligent
and tractable women he introduced the habit.93 Sheltered terraces
enabled patients to rest in the fresh air even in the snow (Figure 1).
Eventually rest in a reclining posture became the most important part of
the regimen everywhere, with patients discouraged from the least exertion
while ill.94 Years later it was demonstrated that lying flat increased
blood flow to the apex of the lungs and may have helped healing—the
same effect as Brehmer had aimed to achieve with exercise.95 By the end
of the 19th century the balance between rest and exercise was similar at
all sanatoria, and the amount prescribed depended on the stage of the
disease. For instance in 1898 a physician from the Brompton, who was a
patient at Nordrach described how one first rested in rooms with wide
open windows, then began leisurely walks which slowly increased until
several miles climbing up to six hundred feet was attained, followed by
further afternoon rest.96
Weber had recommended that delicate children should sleep in well
ventilated rooms and exposed to the night air.97 This habit acquired early
would ward off tuberculosis. For those in sanatoria the rest cure in fresh
open air was continued at night for patients slept on balconies open to
the air or in rooms with open windows with central heating to offset the
Even before Koch had found the tubercle bacillus was excreted from
the lungs, Dettweiler encouraged expectoration by patients but ensured
that the sputum was collected in flasks.98 Once the importance of infection
was accepted the control of sputum became a major focus of public
health campaigns.99
Finally, attention was paid to the role of the patients’ temperament
and state of mind. There was a common belief that there was a romantic
association between the creative arts and the consumptive. Cornet
stressed the importance of addressing the patient’s state of mind with
sympathy and honesty. The aim of treatment was “heightened hygiene
of body and mind.”101 He advised consumptives to shun frivolity and
keep their minds occupied with relaxing activities—reading romances
and crime fiction was too exciting.102 But faced with death the consumptives
had a reputation for high living and fatalism.103
Brehmer also used hydrotherapy for his patients. Patients were subjected
to ice cold douches under high pressure which was one area that
Brehmer personally supervised.104 The practice was an offshoot of his sister-
in-law’s spa and a visit to the influential Priessnitz105 he had made as
a student. Few other centres used hydrotherapy.106
The sanatorium was a world of discipline. As Osler wrote for home
treatment “A rigid regime, a life of rules and regulations, a dominant
will on the part of the doctor, willing obedience on the part of the patient
and friends—these are necessary in the successful treatment of tuberculosis.”
107 Much was asked of the patient, and so it was recommended
that physicians should live in close contact with their patients so as to see
that suitable meals were consumed, and that the rules and regulations
were strictly obeyed.108 Lawrason Brown, Trudeau’s successor at Saranac
informed the patient of “details of treatment and the importance of
implicit obedience.”109 The success of the sanatorium regimen was a
reflection of the strong personality of the physicians.110 Medical paternalism
was expected.
In 1901 The Lancet opened the year with a series of articles in which
leading physicians gave the message that sanatoria were crucial for the
management of phthisis.111 Physicians in Europe and North America
embraced this doctrine, for by 1904 there were 135 sanatoria in existence.
112 Germany led the way with support from state, philanthropists,
and voluntary organizations. Brehmer’s Kurhaus became a magnificent
building, providing accommodation for the rich, middle class, and poor.