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 Görbersdorf 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.

THE DELAY

That there was reluctance to adopt the open-air treatment in Britain is undoubted; many different factors were involved. There was some satisfaction and hope in the progressive year-by-year drop in the mortality rate from tuberculosis, which fell from 3239 per million in 1861-70 to 2429 per million in 1881-90. The complex reasons for this are discussed by Hardy¹² but the clinicians were aware that it was in no way due to their activities. There was still a widespread and strong belief in the merits of climate, the fickle British climate being regarded as unsuitable.

An exaggerated fear of draughts and chills led to closed windows and stuffy, over-heated rooms for patients. ‘All social classes were prejudiced against fresh air, and their prejudices were not without foundation. First, on quasi-medical grounds that are still with us, there was the fear of draughts: the draughts would produce the great British chill, an affliction unknown to the rest of the civilised world’¹². There was, however, no need for the patient with tuberculosis to fear a cold draught. Indeed, Farr had pointed out in 1865 that ‘Phthisis differs essentially in its pathological products, in its complications, and in its fluctuations from bronchitis. For example, the mortality from bronchitis is immediately doubled, or trebled, by a depression of the temperature of the air, while deaths from phthisis exhibit little variation’¹³.

Possibly the daunting magnitude of the problem was the major factor. According to Moore, ‘In a week every bed in every hospital in the United Kingdom might be filled with consumptives, and even then thousands upon thousands might be left without hospital accommodation, so wide-spread is the plague of phthisis’¹⁴. Lindsay, writing in 1897, calculated that a quarter of a million persons were suffering from phthisis in the British Isles¹⁵.

THE OPEN-AIR TREATMENT

Open-air treatment was not considered to be a satisfactory title since it emphasized only one of the factors involved. Nor did the ‘hygienic treatment’ catch on. Later ‘the sanatorium treatment’ was the accepted alternative, even though it was not strictly necessary to go to a sanatorium and the treatment could, in agreed circumstances, be carried out at home. Mander Smyth described the regimen at Nordrach, where he experienced it as a patient and subsequently practised it as an assistant to Walther¹⁶. The first component was fresh air, both by day (out of doors if possible) and by night with wide-open windows. Rest was the next important factor, in bed initially, especially if the patient was febrile, characteristically showing a subnormal morning temperature with a rise in the latter part of the day. Rest included mental rest, with protection from visitors and from talkative neighbours. When the patient was afebrile and the doctor was satisfied with progress, exercise could start, carefully controlled by frequent temperature readings, ideally taken rectally as this was more sensitive to slight changes. Walking began with short distances at a controlled pace avoiding breathlessness; ultimately it would be many miles in a day. The diet was abundant; at Nordrach some patients found it excessive—their three meals had to be finished, even if they vomited. Walther had a strong personality, kept his patients under close observation and expected full cooperation. Patients were conscious that there were always two to three waiting to take their place.

INTRODUCTION IN BRITAIN

The first detailed results of a trial of open-air treatment of tuberculosis in Britain were published in a three-part paper in The Lancet March 5, 12 and 26, 1898, by FW Burton-Fanning of Norwich¹⁷. It subsequently transpired that he was not alone in the experiment and that others had preceded him. If the date of his publication is taken as a mark then those who started this treatment before that date could be regarded as the pioneers, each of whom started to practise the open-air treatment apparently entirely on his own initiative (Box 1).

Box 1.

The timing of the introduction of the open-air treatment to Britain

Who	Where	When
Walker JH	Downham Cottage, Norfolk	July 1892
Philip RW	Victoria Hospital, Edinburgh	August 1894
Burton-Fanning FW	Cromer, Norfolk	Spring 1895
Ransome A	Bournemouth	Late 1895 or early 1896
Moore JW	Newcastle, Co Wicklow	March 1896

Jane Harriet Walker (1859-1938) was born in Yorkshire and had qualified in 1884, the forty-fifth woman to be entered on the General Medical Register. She was an energetic, busy person who was appointed physician to the New Hospital for Women in 1895, having been outpatients physician since 1888. She had been asked what was the new Continental treatment for tuberculosis and, not knowing, promptly went to Nordrach in the Black Forest to find out. She stayed there for a month, studying Walther's methods. In July 1892 she opened a cottage in Downham Market, Norfolk, to treat ‘hospital class’ patients with tuberculosis, following Walther's scheme as far as possible. In 1898, in response to requests from paying patients, she opened a house, Caius College Farm, in the next village, Denver. The house was adapted to sanatorium standards, with ten beds. She treated 35 patients at Downham Cottage and, by May 1899, 43 at Denver¹⁸. In 1901 she opened the purpose-built East Anglian Sanatorium (30 beds initially with later enlargements) in Nayling, Suffolk.

RW Philip (1857-1939) (later Sir Robert) went to Leipzig, and later Vienna, soon after qualifying and it was there, in November 1882, that he first saw tubercle bacilli. Fully aware of the implications of Koch's discovery he returned to Edinburgh determined to pursue a career in tuberculosis. He had little encouragement. 1887 was the year of Queen Victoria's Jubilee, but a proposal to the local Jubilee Committee to open a hospital for the treatment of consumptive patients was turned down. Philip had to be content with an outpatient department in a converted house, the first tuberculosis dispensary. Later, a mansion was acquired and adapted to become the Victoria Hospital for Consumption (14 beds) in Edinburgh. The first patients were admitted in August 1894, and by May 1895 he had treated 62 patients there¹⁹. His concepts for the national management of tuberculosis were immensely influential world-wide and held true for at least the first half of the twentieth century.

FW Burton-Fanning (1863-1937) was a physician to the Norfolk and Norwich Hospital. He visited the Continent frequently and was influenced in fresh-air treatment by WR Huggard of Davos and MG Foster of San Remo. He pointed out that the 24 patients in his 1898 report had had a less than satisfactory application of the open-air method in that there was no resident doctor (he visited once a week or fortnight) and that their diet was less than desirable. Furthermore, since the trial was conducted in a convalescent home, the length of stay was restricted. Nevertheless, his results were better than anything he had achieved before and tubercle bacilli had been eliminated from the sputum of 2 of the 23 originally sputum-positive patients. He opened the first purpose-built sanatorium for the open-air treatment in England at Mundesley, on the North Sea coast of Norfolk, in 1899; and another, for non-paying patients, at Kelling Sanatorium, near Cromer in 1903.

Arthur Ransome (1834-1922) had a particular interest in the public health aspects of tuberculosis and had published extensively. In 1895 he retired to live in Bournemouth but continued some practice as a consulting physician to the Royal Victoria and West Hants hospital. He reported 17 patients, whom he had seen in consultation, who were taken care of in lodgings and boarding houses and treated as thoroughly as possible according to open-air treatment principles. He found good initial results, but most patients had been under care for six months or less—too short, he remarks, to justify any conclusion²⁰.

JW Moore (1845-1947) (later Sir John) had been the last house-physician to Dr William Stokes (1804-1878) and later succeeded him at the Meath Hospital and also as President of the Royal College of Physicians of Ireland. He was involved in opening the National Hospital for Consumption in Newcastle, Co Wicklow, purpose-built for the open-air treatment. It had 24 beds and the first patients were admitted in March 1896. In December 1898 he reported that 200 patients had been treated there and 164 discharged. There had been two deaths and the remaining patients had shown an average weight gain of half a stone (3 kg). Many were at work and others were reported to be well²¹.

THE CLINICAL EXPERIENCE

Few believed that open-air treatment could be tolerated throughout the year in Britain. However, Philip published a table showing the hours spent each day in the open by 35 individual patients during the months of February, March and April 1899, together with the daily hours of sunshine, at the Victoria Hospital in Edinburgh²². This showed decisively that, even in Edinburgh in the winter months, it was not merely feasible but surprisingly popular amongst patients, once they had experienced it and overcome their prejudice. Six to ten hours in the open was not uncommon. Burton-Fanning's experience was similar: ‘fortunately the first contingent of patients soon manifested remarkable improvement and satisfied themselves that their strength, appetite and spirits were increased by the open-air life. New-comers have been taken in hand by the older patients and now the difficulty is to get them indoors at all’¹⁷. Walker found ‘... the general result, extending over several years and embracing in all 78 cases is encouraging, and presents features of hopefulness, even in advanced phthisis, which a few years ago would have seemed quite beyond the bounds of possibility’²³.

Philip, having stressed that not one of his patients had suffered a single accident or disadvantage from time spent in the open, went on to record the clinical response to this management. He found ‘a remarkable benefit’ and ‘positive results of most satisfactory and far-reaching character’. Within a week of starting the treatment the patient's colour and appearance were found to have altered to a robustness similar to that developing during a sea voyage. Any tendency to digestive disability was replaced by a strong appetite, almost a craving for food. Weight increase was phenomenal, as much as two to six pounds in a week, and this might be progressive. The cough, the commonest symptom of tuberculosis, was seldom heard and the sputum quickly lessened in quantity and became more mucoid in character, finally often disappearing altogether. Night sweats tended to cease within days. The pulse rate soon lessened and the beat became more forcible. Cold extremities and any tendency to shiver disappeared. The temperature, which might have been swinging before admission, would within a week or two settle and soon take a subnormal pattern²². Philips' fellow authors found similar changes, though maybe not occurring so quickly—possibly because they did not apply the treatment so rigorously.

This response to treatment was indeed remarkable and it was clear that, for the very first time, clinicians now had a degree of control of tuberculosis; they were in no doubt that they had interrupted the natural history of the disease as shown by objective clinical evidence.

The extent of the control remained to be discovered and, because there was no agreed classification of the severity of the disease, or even of the terms used to express outcome, there was no prevailing climate for a thorough scientific evaluation by clinical trial in those days.

The ideal patient would have a short history and few signs of toxicity. Just how long it would be necessary to be an inpatient remained to be discovered. It would certainly be more than the two or so months generally allowed at that time; Burton-Fanning thought a year might be needed¹⁷. The hold on the disease was slight, so control of the patient's day-to-day activities had to be strict. Weber wrote supporting the case for sanatoria and constant daily advice: ‘... a single imprudent act, such as a long walk, an over-exertion in active games, a dance, or sitting up at night in a room full of smoke, can postpone for many months, or destroy for ever, the chances of recovery.’ Philip warned, ‘In so chronic and treacherous a disease it is not wise to speak confidently of cures effected’.²⁵ Bardswell attempted to make a true judgment of the value of sanatorium treatment with a careful follow-up²⁶. He reported the outcome of patients admitted to King Edward VII Sanatorium in Sussex between 1907 and 1914. The patients were middle-class and thus had better conditions to return to; the ‘hopeless cases’ were not included, and there was therefore a bias in favour of recovery. Nevertheless, 751 of the 1707 admitted (44%) were dead by 1916. So, even under the very best conditions, this was a devastating disease to catch.

THE NATIONAL CRUSADE

Conscious of the previous inactivity and neglect of the huge tuberculosis problem and with a growing awareness of lagging behind the Continent, a movement was forming to push for action. The editor of The Practitioner, Malcolm Morris, who was in part responsible for this, decided to devote the June 1898 edition of the journal to giving background information to help initiate a crusade. The dozen or so articles included papers by Weber and Burton-Fanning on the open-air treatment. The leading article pointed out, ‘In most civilised countries there are signs that the government and the people, as well as the medical profession, are awakening to the importance of the matter’. It continued:

‘... it is of national importance, as it closely concerns the maintenance of the vigour of the race. On this ground the co-operation of the State might well be asked. In this country it is notoriously difficult to get even enlightened statesmen to attend to anything out of which party capital cannot be made. But even here the day is surely, if somewhat slowly, coming when ordinary legislators will be brought to recognise that the public health is the first and greatest of political questions. Let us, in short, have a national crusade against a national disease’.

A major point of the campaign was to provide a sanatorium system to cover the poorer classes. Without the open-air treatment sanatoria could have offered only isolation and terminal care, little better than the workhouse infirmary.

The crusade caught on, in particular when the Prince of Wales agreed to chair a meeting at Marlborough House in December 1899 to support the newly formed National Association for the Prevention of Consumption. The Prince had visited Falkenstein sanatorium near Frankfurt while staying with this sister the Empress Frederick at Kronberg and had been greatly impressed²⁷. Some forty prominent physicians and politicians attended and the Marquis of Salisbury, then Prime Minister, spoke:

‘I believe that it is true, as Sir William Broadbent says, that we are very much behind the world in these matters. We are behind the world in practical efforts. We are even behind the world in theories of the matter, for I believe it is quite a recent event that the contagious character of consumption has been fully acknowledged in this country’²⁸.

PUBLICITY AND ACCEPTANCE

The open-air treatment was given further publicity when the July 1899 copy of The Practitioner was again devoted to tuberculosis, with articles by Philip, Burton-Fanning and Walker. Support also came from Clifford Albutt (Regius Professor of Physic at Cambridge), and Trudeau wrote from America about his experiences in the Adirondacks. Dr Roland Thurnam, who had been a patient at Nordrach, reported the results from his sanatorium in Somerset. The annual meetings of the BMA, in Edinburgh in 1898 and in Portsmouth in 1899, were again venues where the open-air treatment was discussed. Numerous meetings were held throughout the country in support of the National Association for the Prevention of Consumption. No-one spoke against it and Burton-Fanning was able to report, in October 1900, at a discussion on the Therapeutics of Open Air, ‘... the complete absence of any opposition to a form of treatment, which is anyhow novel in some particulars, is a very remarkable and exceptional form of testimony for a medical departure’²⁹.

CONCLUSION

An anonymous foreword to the Medical Research Committee Special Report on the Mortality after Sanatorium Treatment (1919) states ‘The only statistical criterion of the absolute value of sanatorium treatment would be given by a comparison between the rates of mortality of sanatorium patients and those of tuberculosis patients who were similar in age, sex, and economic position, but treated on other lines or untreated.’ No such study, or similar statistical comparison was undertaken and it will never be known whether sanatorium treatment was a success or a failure. However, ‘Physicians of long and intimate experience of the disease are unanimous in the opinion that the introduction of sanatorium methods has materially improved the outlook for the average consumptive, and that residence in a sanatorium represents the best treatment available at the present time’²⁶. There is no doubt that the open-air treatment was an improvement on the ‘cod liver oil era’ it replaced and its influence was not challenged until the advent of chemotherapy. The clinicians who introduced the open-air treatment to Britain deserve recognition and credit.