Rest and Fresh Air: The Sanatorium Movement
This is the third installment in our series “The Sanatorium Files.”
Without the scientific understanding needed to develop effective therapeutics to fight tuberculosis in its many forms, doctors, patients, families and charlatans looking to make a profit tried a wide range of treatments to offer any hope of relief and a cure (see the Timeline of TB Treatments). One of the most universal and pervasive approaches for people with the most common pulmonary form of the disease was that of rest and fresh air for patients, leading to the creation and proliferation of sanatoriums, or long-term TB treatment hospitals/resorts in Europe and the U.S.
Rest and fresh air were quite possibly the first treatments used for tuberculosis patients in ancient days. Though records of all treatments tried so long ago are limited, we do know that mummified remains from 3,000 B.C. in Egypt showed what appeared to be sanatoriums for TB patients. Romans in A.D. 200 were some of the first to recognize this characteristic of the disease, and tuberculosis sufferers were often sent on long ocean voyages in hopes that sea breezes and salt air would improve their condition.2
Possibly the first sanatorium for the treatment of TB in recent times was the Royal Sea Bating Infirmary for Scrofula, founded by Quaker physician John Cockley Lettsom in Margate, England in 1791. Built for 36 patients and later expanded to 86, the building was designed so patients could sleep on open but protected balconies and spend most of the day in gentle exercise or resting on the beach. Lettsom’s approach received a lukewarm response and not much attention from the medical community.1
Dr. George Bodington, an English physician, who advocated for the “open-air cure”, was clearly ahead of his time. In 1840, he wrote a scathing attack on tuberculosis treatments common at that time, including imprisoning patients in hermetically sealed rooms (which also, unknown at the time, infected their caregivers and family members) and published his essay, On the Treatment and Cure of Pulmonary Consumption.1
Bodington rented a house near his home in Maney, England and opened a sanatorium where patients could take advantage of the fresh dry air, exercise and a nutritious diet. Response from the medical establishment was quick and harsh, with many noted doctors of the day condemning his approach, and TB referrals to his sanatorium waned. He became discouraged about tuberculosis and devoted the remainder of his professional life to the care of the mentally ill. Bodington’s contributions to TB treatment were recognized as the sanatorium movement took hold with a posthumous amendment to his obituary notice in the Lancet in 1882, expressing surprise that “a simple village doctor in the 1840s should have arrived at conclusions which anticipated some of our most recent teachings.”1
Sanatorium Approach Becomes Standard of Care
Hermann Brehmer, a German physician, is credited with opening the first sanatorium of the sanatorium movement in 1854 in the village of Göbersdorf in the Baravarian Alps. It was a live-in hospital made up of cabins where patients could get plenty of fresh air, a healthy diet, and prescribed rest and exercise.
“To make it easier for patients to complete their prescribed walks – not an inch more, not an inch less – [Brehmer] had weatherproof wooden benches fixed into the ground at regular intervals along the forest paths, a bold innovation that was to survive the age of sanatoria and from Yalta to Hampstead Heath and from Kyoto to New York’s Central Park still commemorates his obdurate faith.”1
Commitment to the structured regimen of sanatorium life, while not a cure, did offer a degree of remission to some patients, probably by helping to strengthen their own immune systems. Sanatoriums also provided the added benefit of separating the infected from others. Once diagnosed, patients went to a sanatorium for week, months or years.
“The basis of sanatorium life was organization and optimism. Daily activity—from brushing teeth to talking to reading—was regulated and controlled. Positive thinking was encouraged. Death was never mentioned. Even in the middle of winter, patients spent time swathed in blankets on chaise lounges on patios and in front of open windows, breathing in fresh air, soaking up all the sunshine they could get.”2
Construction of many more sanatoriums followed throughout Europe. There was no set treatment approach, and the hospitals varied by country, region and even by director.
In Switzerland, many sanatoriums were more like spas, focusing on food and entertainment activities for patients, with a high price tag catering to more wealthy patients. Lavish mountain resorts the village of Davos were very popular and formed the setting for The Magic Mountain a famous book by Thomas Mann featuring a main character that spends seven years recovering from TB in Davos. In England, Dr. Marcus Paterson at Brompton Hospital focused on manual labor of increasing degree, which provided a way for poorer patents to go to a sanatorium for treatment and most certainly helped reduce the cost of running the facilities.1
Sanatorium Movement Crosses the Pond
The first sanatorium in the U.S. was opened in 1885 in Saranac Lake, New York by Edward Livingston Trudeau, an American doctor who had planned to spend his final days in the Adirondack Mountains but found that his symptoms disappeared in the fresh air.2
Trudeau had read about the Brehmer approach and sought to replicate it. He also read about Koch’s discovery of the TB bacterium and set up his own experiments to test the germ theory on animals and how they were affected by different levels of activity, light and food, attempting to quantify the sanatorium approach to treatment, with mixed results that he thought supported the fresh-air cure. He presented his findings in 1887 to a meeting of the American Climatological Association. He continue to care for many patients but was not actually cured himself, continuing his work as his disease receded and surged, and ultimately he died of TB in 1916.1
A 2009 documentary, “ON THE LAKE: Life and Love in a Distant Place,” provides an in-depth look at what life was like in an American sanatorium. The film tells the true story of the tuberculosis epidemic in America and globally today through the lives of those that were infected and who died –– but also of those who survived, with never-before-seen footage and stills, interviews with TB experts, and interviews with TB survivors and their relatives. It features state-run Zambarano Hospital on remote Wallum Lake in northern Rhode Island, Trudeau’s sanatorium at Saranac Lake, N.Y., the largest treatment center for TB patients east of the Mississippi; and sanatoriums in Denver, Colorado, the largest center in the West; Massachusetts; Baltimore, Maryland; and North Carolina.
Holding On to Hope
Even with mixed results, the sanatorium movement was the only available treatment that seemed to show any impact at all on the disease before the development of antibiotics in the 1940s, so for almost 100 years, around a thousand sanatoriums, at first private and then also public (operated by cities, counties and states) continued to be built throughout the U.S and across Europe as patients, families and physicians waited and hoped for a real cure.
Although they were widespread, sanatoriums only accommodated a small fraction of the millions of TB victims. Not wanting to register deaths, the hospitals often did not accept people with more advanced disease, and because of the cost of sanatorium care, poor patients were left to die at home with their families.3
In the final analysis, the death rate in sanatoriums or at home were the same – about half of patients died whether they were treated in a sanatorium or not treated at home. For example, 12,500 TB patients were treated at the Trudeau sanatorium at Saranac Lake, and when it closed in 1954, 5,000 were still alive.4
The End for Sanatoriums: The Madras Experiment
Once antibiotics were discovered that provided a real cure for TB for the first time, sanatoriums declined and closed rapidly. A controlled study called the Madras Experiment, conducted in Madras, India (now called Chennai) over several years starting in 1956 sought to discover whether pulmonary TB patients could be treated as effectively and safely with anti-tuberculosis drugs (isoniazid and p-aminosalicylic acid) in their own homes as in sanatoriums. The study showed that in fact the results provided by the treatments were the same whether delivered while resting in a sanatorium or carrying on with regular daily life at home. It also showed that the risk of contagion to relatives and others close to patients was similar and very limited once drug treatment started both in the hospital and at home, debunking the sanatorium movement once and for all.
A report on the Madras Experiment in The Lancet in 1961 summarized the results and highlighted the century-old ingrained traditions of rest, fresh air and segregating TB patients from the healthy population:
“But traditional beliefs are difficult to change; and it may be as difficult to modify the tradition of segregation as it apparently is to learn the other great lesson of the Madras experiment—that tuberculosis can be treated by chemotherapy alone, even when patients continue hard manual work and remain undernourished. Rest and good food may be pleasant for the patient; but they are not necessary for his recovery.”5
Impact of Sanatoriums Today
Though sanatoriums had no effect on curing tuberculosis, according to Lee B. Reichman, MD, MPH and Janice Hopkins Tanne in their book “Timebomb: The Global Epidemic of Multi-Drug-Resistant Tuberculosis,” they did provide a long-term benefit to society and medicine:
In sanatoriums, “the entire specialty of pulmonary medicine took root. The physicians at these sanatoriums, many patients themselves, later became interested as well in other aspects of lung disease such as asthma, emphysema, and lung cancer.”6
The Madras Experiment provided the final nail in the coffin for almost all sanatoriums. However, because TB continues to kill millions worldwide, drug-resistant strains continue to cause long-term treatment challenges and the disease still continues to appear in the U.S., several sanatoriums and special tuberculosis units in hospitals still care for patients in the U.S. today, in the last remaining American sanatorium in Lantana, Florida and Los Angeles. These facilities provide a valuable service, segregating drug-resistant TB patients to limit spread of these dangerous strains while supporting patients during the extended 18+ month treatment regimen as we wait for more effective drugs to eliminate this global threat.
Sources: 1“The White Death” by Thomas L. Dormandy, 2000, New York University Press/1999, Hambledon Press; p. 148, 57-59, 57-59, 151, 162-165, 178-186. This extract is printed by kind permission of the Continuum International Publishing Group. (www.continuumbooks.com)
2“Tuberculosis” by Diane Yancey. Text copyright © 2008 by Diane Yancey. Reprinted with the permission of Twenty-First Century Books, a division of Lerner Publishing Group, Inc.; p. 24, 25-26, 25. All rights reserved. No part of this text excerpt may be used or reproduced in any manner whatsoever without the prior written permission of Lerner Publishing Group, Inc. (www.lernerbooks.com)
3 “Tuberculosis” by Elaine Landau, 1995, A Venture Book; p. 22-23
4 “The Tuberculosis Update” by Alvin and Virginia Silverstein and Laura Silverstein Nunn, 2006, Enslow Publishers, Inc.; p. 22
5 “The Madras Experiment,” The Lancet, Volume 278, Issue 7201, 2 September 1961, Pages 532-533
6 “Timebomb: The Global Epidemic of Multi-Drug-Resistant Tuberculosis” by Lee B. Reichman, MD, MPH, and Janice Hopkins Tanne, 2002, McGraw-Hill, www.mcgraw-hill.com ; p. 21.