The Key to the Sanatoria

The clinician in Britain in the 1890s knew that no effective treatment could be offered to a patient with tuberculosis. Even the diagnosis presented formidable difficulties. It had to be made on an evaluation of the patient's symptoms and on the findings of a physical examination of the chest. The pulse could be counted, the temperature taken and the patient weighed. Since Koch's discovery and demonstration of the tubercle bacillus in 1882 the sputum could be examined and, if positive, was an invaluable and decisive test. There were, however, no X-rays to show the extent of the disease or the presence of cavities in the lungs, nor even an erythrocyte sedimentation rate to reflect the degree of tissue damage, so it was difficult to categorize degrees of severity. From these uncertain foundations the clinician would have to make an attempt at prognosis, with little available guidance. He (it would nearly always be a he) could turn to Pollock's study of 3500 patients who, during the seven years before 1865, had attended the outpatients at Brompton Hospital; these were ‘patients of all classes below the wealthy’1. Pollock found that the survival time was longer than expected, probably exceeding four years. Another study looked at a different population; Williams reported 1000 patients ‘selected from private practice, the patients for the most part belonging to the upper and middle classes of society’ from 1842 to 1864, and found that at best a span of eight to ten years could be expected2. Then there was the awkward problem of when, or even whether, to tell the patient. Typically, he or she would be under forty years old, with family responsibilities. The prospect was a chronic illness with intermittent periods of increasingly debilitating ill-health, ultimately to be fatal, for which the clinician had little effective palliative treatment to offer. (This has been referred to as the ‘cod liver oil and mist.gent.alk’ era.) The only hope lay in the patient's bank balance; there was just the possibility, if the disease was caught early enough and if he or she could afford to travel, that a ‘cure’ might be achieved. Clearly this option excluded the vast majority of patients who were impoverished. Selecting a suitable climate was the proffered solution. Which climate was to be recommended was less clear; some experts were advocates of high altitude—the exhilarating Alpine winter made Davos very popular—but so was the seaside—Cannes and Menton had their attractions. Weber, in a detailed review, recommended matching the climate to the patient's constitution3. Such success as there was probably resulted from the patient spending long hours in the open air. On the Continent the ‘open-air treatment’ in sanatoria was also available. This was a much more systematic regimen with the patient under the direct, often daily, supervision of the doctor. The open-air treatment was not unknown in Britain, for George Bodington of Sutton Coldfield had been the first to describe and to practise it. His ideas were an abrupt change from the traditional teaching and when he published his theory and experience in 18404, The Lancet's reviewer dismissed its ‘very crude ideas and unsupported assertions’5. Bodington turned to other things. Henry MacCormac of Belfast had a similar experience and when his paper on the evils of rebreathed air (‘True Nature and Absolute Preventability of Tubercular Consumption’) was presented in 1861 to the Royal Medical and Chirurgical Society of London, they rejected it and scornfully refused him a vote of thanks6. Benjamin Ward Richardson in 18577 and John Henry Bennet in 18668 both described the hygienic treatment of pulmonary consumption but no one followed their advice in Britain. In 1885 Hermann Weber pleaded for open-air treatment in Britain in his Croonian Lectures to the Royal College of Physicians9; in 1889 the BMJ published a leading article describing Dettweiler's regimen in Falkenstein sanatorium in the Taunus Mountains near Frankfurt10, and Harris and Beale in their textbook11 gave a clear description of the open-air treatment in 1895. There were many other such publications and the subject was constantly before the profession. The first German sanatorium for the systematic open-air treatment had been started by Hermann Brehmer (1826-1889) at Gorbersdorf in Silesia in 1854. To start with it was a small group of cottages; ultimately it would grow to 300 beds. Brehmer advocated high altitude (it was at 518 m), abundant diet with some alcohol, and exercise in the open air under strict medical supervision. The results were regarded as highly successful, surpassing any previous treatment. Peter Dettweiler (1837-1904)—his patient who later became his assistant—opened Falkenstein sanatorium in 1876. He continued Brehmer's work but placed a greater emphasis on rest. His patients spent the day in Liegehallen, lying on chaises longues, sheltered by a roof but in the open air. When Dr Otto Walther's English wife, Hope Bridges Adams, developed tuberculosis Dettweiler recommended that they should go to the Black Forest, and it was at Nordrach that Walther (1853-1919) guided her back to health. In 1888 he started to accept other patients, expanding to about 50 beds at any one time. Nordrach was considered by some to be the finest development of the Continental sanatorium treatment.