Peter Warren : The Evolution of the Sanatorium (extract )
The priority of all sanatoria was to expose the consumptive to the
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
cold
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
and voluntary
organizations. Brehmer’s Kurhaus became a magnificent
building, providing
accommodation for the rich, middle class, and poor.
