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This is to certify that the

thesis entitled

In the Center of the Plague: Tuberculosis
and the Experience of Space, Time and Teleology,
1910-1940

presented by
Beth O'Donnell Linker

has been accepted towards fulfillment
of the requirements for

Master of Arts degree in Health & Humanities

December 12, 1999
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IN THE CENTER OF THE PLAGUE:
TUBERCULOSIS AND THE EXPERIENCE OF
SPACE, TIME AND TELEOLOGY, 1910—1940

By

Beth O’Donnell Linker

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF ARTS
Interdisciplinary Programs in Health and Humanities

1 999

ABSTRACT
IN THE CENTER OF THE PLAGUE:
TUBERCULOSIS AND THE EXPERIENCE OF
SPACE, TIME AND TELEOLOGY, 1910—1940
By

Beth O’Donnell Linker

In this project, I examine what it was like to be a tuberculosis patient in the
American sanatoria of the early twentieth—century. Several historians of the sanatorium
experience have argued that these institutions should be considered incarcerative, similar
to prisons and lunatic asylums of the day, insofar as they greatly restricted individual
freedom. I take this work a step further by focusing on a sanatorium treatment that
enforced a particularly extreme form of confinement and restriction: prolonged and
complete bed rest. I show that, despite the medical community’s best intentions, this
treatment was “psychically invasive.” That is, bed rest contributed to bringing about a
fundamental change in how patients related to the world around them, eventually

resulting in a radical alteration of their perception of space and time, as well as their

conception of life goals.

For my mother and the memory of my father

iii

ACKNOWLEDGEMENTS

It gives me great satisfaction to be able to thank those individuals and institutions
whose assistance contributed to the completion of this project. First, I would like to
express my gratitude to chair of my thesis committee, Peter Vinten—Johansen. No one
could ask for a more responsive advisor or dedicated teacher. I would also like to thank
the other members of my committee, Steve Rachman, who was largely responsible for
inspiring me to undertake this project, and Tom Tomlinson, who encouraged my
scholarly pursuits in the Interdisciplinary Programs in Health and Humanities from the
beginning of my graduate education. In addition to the comments and suggestions of my
committee members, the project also benefited from the helpful insights of Maureen
Flanagan. On a more personal note, I wish to recognize my mother, to whom this thesis
is dedicated, for her steadfast love and support of my professional endeavors. And
finally, I want to thank my husband, Damon Linker. I am grateful for his ideas and
suggestions as well as his abiding support and commitment, all of which made the
completion of this project possible.

The research and writing of this thesis was conducted with financial support from
a number of sources, including an Excellence Fellowship granted by my degree program
and a College Merit Fellowship, granted by the College of Arts and Letters at Michigan

State University. I have benefited greatly from the generosity of these organizations.

iv

TABLE OF CONTENTS

INTRODUCTION

CHAPTER 1
THE TRIUMVIRATE: REST, FOOD AND FRESH AIR

CHAPTER 2

“AN ISLAND OF ACTIVITY”: SANATORIUM SPACE
The Confines of the Sanitorium
The Life of the Horizontals
In the Kingdom of the Sick

CHAPTER 3

THE POSSIBILITIES OF PROJECTION: SANATORIUM HORIZONS
The Patient’s Worldview
Restlessness
Narrowing the Horizon

CHAPTER 4

THE TEDIUM OF TB: SANITORIUM TIME
The Relativity of Time
The Obstacle of Time
The “Inelastic Present”

CONCLUSION

BIBLIOGRAPHY

24

38
39
43
49

55
56
62
66

70
71
77
78

84

87

INTRODUCTION

It was October 193 8, the third week of her sanatorium stay, and Betty MacDonald
had been confined to bed for a total of twenty—one days. Looking for something to divert
her attention from the “cold, green walls” around her, she reached toward her nightstand
for a copy of the sanatorium rule—book, a pamphlet that every patient received upon
admission, and skimmed through some of the introductory lessons about tuberculosis.
Lesson number five ended with the following rule: “The cure of tuberculosis is not
medicine but a new regime of living.”l

This quotation captures the essential character of the tuberculosis experience in
the sanatoria across the United States between 1910 and 1940. In the early twentieth-
century, patients with tuberculosis were rarely treated with pharmaceuticals. Instead,
they were often advised to take up residence at a sanatorium, to leave the activities and
demands of their daily lives behind, and to move to a place where they could “take the
cure” of rest, fresh air, and a healthful diet.

When attempting to understand the history of medicine in the early twentieth-
century, it is important to draw a distinction between what physicians knew about the
mechanism of disease and how they applied that knowledge to treating patients.2 With
the rise of the laboratory sciences throughout the latter part of the nineteenth—century,
significant breakthroughs were being made to explain the cause of the disease, but
relatively little gain was made in terms of treatment. Prior to the bacteriological era,
most physicians in the United States understood tubmculosis (or what they called

phthisis) to be a noninfectious disease acquired as a result of hereditary predisposition

 

' Betty MacDonald, The Plague and I (New York: J.B. Lippincott Company, 1948), 128.
2 Clive Seale and Stephen Pattison, Medical Knowledge: Doubt and Certainty (London: Open
University Press, 1994), 48.

and the environment (through vitiated air). But with the 1882 bacteriological findings of
a German scientist named Robert Koch, American physicians of the early twentieth—
century began to accept the theory that tuberculosis was caused by a microscopic
organism, called the tubercle bacillus, which traveled from person to person.

Although empowered with knowledge of etiology, the medical community had no
direct means to eradicate the newly discovered tubercle bacillus. In fact, up until mid—
1940s, there were no known drug therapies that could consistently and effectively combat

tuberculosis.3

Pharmaceuticals from the pre—bacteriological era, such as cod liver oil
and cresote, were discounted by most physicians of the early twentieth—century as
remedies that magnified rather than alleviated the symptoms of tuberculosis.4 Thus,
throughout the first third of the twentieth—century, physicians mostly relied on
noninvasive therapies, or what they saw as “the things [given by] nature,” such as
nutrition, rest and fresh air. 5 And the sanatoria were increasingly seen as the best places
to administer this treatment regime.

The rationale behind the sanatorium regime went through many evolutionary

stages between the nineteenth— and twentieth—centuries. The original sanatorium,

founded by the German physician Herman Brehmer in 1854, was instituted on the belief

 

3 Streptomycin, discovered by Selman A. Waksman in 1943, was usefitl only up to a point, for the
drug was limited because of adverse side-effects. While many were looking for the “magic
bullet” throughout the early twentieth—century, medical researchers realized that waxy coating of
the tuberculosis bacteria precluded a single drug treatment. Thus multiple drug therapy, using a
combination of drugs, over a lengthy period of time is prescribed for today’s cases of
tuberculosis. In 1951, a synthetic drug known as isoniazid took the place of streptomycin. For
more on the history of chemotherapy treatments for tuberculosis see Linda Bryder, Below the
Magic Mountain: A Social History of Tuberculosis in Twentieth—Century Britain (Oxford:
Clarendon Press, 1988), 253—265, as well as Scale and Pattison, 55-58.

4 See Charles Rosenberg's discussion of "therapeutic nihilism" that became prevalent among
many American physicians as well as the lay sector in the late nineteenth-century United States
in The Cholera Years: The United States in 1832, 1849, and 1866 (Chicago: The University of
Chicago Press, 1987), 223ff.

5 Will Ross, 1 Wanted to Live (Milwaukee: Wisconsin Anti—Tuberculosis Association, 1953), 86.

that insufficient pulmonary circulation and poor general nutrition caused tuberculosis.
Brehmer built his sanatorium in the Swiss Alps, for he believed that reduced atmospheric
pressure would increase heart rate and metabolism, which would, in turn, increase
pulmonary circulation. His sanatorium regime was based on diet, mountain air, and a
careful balance between rest and exercise. Most importantly, rest was usually only
prescribed when the patient was in a febrile state.6 Edward Trudeau, a physician who
suffered from tuberculosis himself, imported the sanatorium idea to America in 1885. He
built the first sanatorium in America, situated in the remote mountainous Adirondack
region of upstate New York. Although heavily influenced by Brehmer, Trudeau had
different theories about disease causation and treatment, which ultimately formed his
belief that rest should play a more dominant role in the American sanatorium than it did
in Europe. By the 19208 and 1930s, some of the largest and most prominent sanatoria
across the United States were adopting prolonged rest even for those patients who were
asymptomatic. In fact, in certain sanatoria it became protocol to prescribe bed rest for up
to three months for every newly admitted patient]

From the perspective of physicians and researchers of the early twentieth-
century, the claim that the cure for tuberculosis was “not medicine but a new regime of
living” makes sense given the fact that, at that time, most pharmaceuticals (or
“medicine”) would only worsen the disease rather than help to cure it. But while
knowledge of medical theories of disease—causation and treatment can illuminate the

history behind the rise of the sanatoria movement of this century, it by no means gives us

 

6 R. Y. Keers, Pulmonary Tuberculosis: A Journey down the Centuries (London: Bailliere
Tindall, 1978), 76—77.

7 Joseph H. Pratt, ”The Development of the Rest Treatment in Pulmonary Tuberculosis," The New
England Journal of Medicine 206 (1932): 68—69.

access to the whole story from all of the available perspectives. To provide a firller
account, we need to explore the accounts of patients who were treated in the sanatoria
and ask such questions as: How did MacDonald herself understand the lesson in her rule
book that stated that the cure for tuberculosis required a “new regime of living?” How
did patients who were admitted to sanatoria across the United States perceive their illness
and the prescribed treatment regime? And, above all, how did the treatment of prolonged
bed rest, which became prominent in the American sanatoria, impact the patients who
underwent it?
It! :- t

Tuberculosis is a topic that has intrigued a wide—array of scholars in various times
and places. It is a disease with a long history, dating back to Ancient Greece, and has
probably been “responsible for more destruction of life and debilitation than any other
infectious disease.”8 In the United States, for example, tuberculosis was the most
common cause of death in the nineteenth-century, and continued to be one of the leading
causes of death well into the twentieth—century. The disease had such a destructive
presence that it was often called the “white plague,” and the “captain of all these men of
death.”9 Prior to Koch’s discovery of the tubercle bacillus, the disease was most widely
known among the lay population as “consumption,” a term which vividly described the
end stages of the disease when a patient’s body would literally waste away. It was not
until some sixty years after Koch’s discovery, though, that an effective treatment for
tuberculosis was found. The discovery of streptomycin in 1946, and the subsequent

chemotherapeutic agent, isoniazid, greatly reduced the cases of tuberculosis in the United

 

' Scale and Pattison, 36.

9 Rene and Jean Dubos, The White Plague: Tuberculosis, Man and Society (Boston: Little,
Brown and Company, 1952), 3—10.

States by the mid—twentieth-century, which, in turn, led to the eventual demise of the
sanatorium system.10
Most historical works about tuberculosis in the United States and Great Britain
focus on the late nineteenth— and early twentieth—centuries, for this was a time of great
change in science, medicine and social policies.” The discovery that tuberculosis was a
contagious rather than an endemic disease caused by heredity and environment factors,
led to widespread public health measures to control the spread of disease. For instance,
by 1890, many of the temporary city and state public health departments which were
concerned with broad environmental sanitation throughout the nineteenth—century, had
become permanent structures, concerned with the individuals who harbored the deadly
germs. No longer bound to broad notions of environmental causes of disease (such as
miasma) and armed with laboratory tests, public health officials could pinpoint the cause
of disease down to the very individual who carried the deadly germs. For public health
officials, laboratory medicine thus offered a great deal of hope, for it was seen as a ticket
to a better life and healthier society which would no longer be beset by the devastating

diseases of the nineteenth—century. At a time in which tuberculosis was seen as “a source

of inefficiency and waste, a brake on the progress of the nation,” the optimism of the

 

'0 It should be noted that this is only one interpretation of the history of tuberculosis and the
sanatorium. As one of the few historians dealing with post war tuberculosis, Barron H. Lerner
takes issue with this popular interpretation of the demise of tuberculosis and the sanatorium
system. See Barron H. Lerner, Contagion and Confinement: Controlling Tuberculosis along the
Skid Road (Baltimore: The Johns Hopkins University Press, 1998), 1-10. Using Seattle as a case
study, Lerner demonstrates that during the post WWII years, “tuberculosis remained a major
health problem, particularly in poor, urban communities.” (Lerner, 4) In his view, the newly
discovered streptomycin was not a panacea—the same social problems of poverty and
noncompliance persisted throughout the 19505 and 19608. As a result, Lerner demonstrates that
Seattle authorities became particularly “zealous in its use of quarantine and detention” in the
antibiotic era. (Lerner, 6)

" Lemer's book is an exception to this claim. Also Bryder dedicates a portion of a chapter in
Below the Magic Mountain to the post-war therapies and their effects. See Bryder, 214—226.

laboratory sciences fueled grand-scale public health campaigns, and more specifically,
anti—tuberculosis crusades, which sought to prevent the spread of the disease, with the
ultimate goal of ushering in a new society of healthy citizens. '2
In the initial years of the campaign, public health officials envisioned a two—
pronged task force, which would lead the fight against tuberculosis. Public health
departments essentially took on the task of disease prevention, while sanatoria adopted
the goal of providing a cure for those already effected by the disease.13 As for the task of
disease prevention, several measures were employed, the first of which was tenement
housing reform. But the measure of prevention that held the most promise (at least in the
minds of that public health ofiicials) was education. As Michael Teller writes, “the faith
in the efficacy of education as a tool for'social progress was widespread throughout the
Progressive Era.”l4 In movie houses, in the schools, and inthe streets, pamphlets and
posters were dispersed which advised the public to avoid spitting, always to cough in
handkerchiefs, and to open windows for fresh air and sunlight. In fact, in some cases
such advice eventually became law, with certain cities passing ordinances, which
prohibited spitting in public places.” Overall, the main thrust of the educational
campaign was to disabuse the public of its belief that tuberculosis was a hereditary
disease—in order to control the spread of infection, the public had to understand its

contagious nature.

 

'2 Michael E. Teller, The Tuberculosis Movement: A Public Health Campaign in the Progressive
Era (New York: Greenwood Press, 1988), 33.

'3 Sheila M. Rothman, Living in the Shadow of Death: Tuberculosis and the Social Experience of
Illness in American History (New York: BasicBooks, 1994), 180.

“ Teller, 56.

'5 Teller, 21.

As the campaign against tuberculosis progressed into the early decades of the
twentieth—century, public health officials increasingly took on the role of the guardian to
the greater health of the society, and thus wielded a great amount of power over
individuals who were found to have tuberculosis. By 1904, mandatory registration of
those who were sick was common in many cities. In effect, physicians were required by
law to report the addresses of persons with tuberculosis so that a sanitary inspector (a
representative of the board of public health) could visit the home of the infected person.
The inspector would often provide the tubercular person with education pamphlets, and if
the patient was in the advanced stages of the disease or understood to be harmful to the
community, the inspector ofien had the “legislative, judicial, and executive powers” to
forcibly confine the patient to a hospital or sanatorium.16 Public health officials took on
this power with the optimistic belief that nothing could stand in the way of their goal of
eradicating the tubercle bacillus, not even the individual who carried the microbes.
Narrowing their scope to the cellular level, public health officials tended to look past the
particular individual with whom they were fighting. In their minds, one person’s liberty
was expendable if it meant eliminating disease. The equation was simple and utilitarian:
isolate the deadly germs found in the one for the greater good of the many.

As the educational campaigns reached more people and as the trust in the
laboratory sciences grew, so too did the fear of contagion. Much of the healthy populace
became less tolerant of (and sometimes even hostile to) those with tuberculosis.'7 In fact

by the early twentieth—century, the term phthisiophobia was used to describe the

 

'6 Judith Walzer Leavitt, Typhoid Mary: Captive to the Public ’s Health (Boston: Beacon Press,
1996), 42. The first mandatory testing for tuberculosis was instituted in New York City in 1897.
(Teller, 22) By 1904, testing became a more widespread measure for tuberculosis prevention
throughout the United States. (Rothman, 189)

‘7 Rothman, 211—217.

increasing fear of tuberculosis.'8 For the patient, the diagnosis of tuberculosis was a kiss
of death both physically and socially. Those with tuberculosis not only had to contend
with the disease, but they also had to face the possibility of permanently losing their jobs,
being separated from their families and communities, and confronting a potential life-—
time of stigmatization. Having tuberculosis at a time when society was largely driven by
fear has led historians like Linda Bryder to conclude that “the social consequences of the
disease were far worse than its physical manifestations.”19
While public health officials were trying to locate new cases of tuberculosis in the
hopes of preventing the Spread of infection, physicians in the sanatoria were chasing the
cure. Koch and other researchers were quick to point out that the emphasis on the
bacillus as the sole and primary causative factor of the disease was wrongheaded, for
although exposure was an important factor in disease causation, not everyone who was
exposed to the bacillus developed the disease. Koch believed that secondary factors such
as an individual’s nutritional status, living conditions, and emotional state were very
influential when it came to contracting tuberculosis. Following hard on the heels of
Koch, Dr. William Osler argued in 1894 that “it was important to consider not only the
seed (the bacillus) but also the soil (the patient) when analyzing why a given person had
become tuberculous.”20 The sanatorium was thus largely concerned with the “the soil”
half of the equation, for many physicians believed that a sufficiently well—rested, well—
nourished, healthy person could resist the tubercle bacillus. Moreover, many in the

medical field thought that the typical sanatoria regime could not only aid the already

 

'3 Rothman, 190. Phthisis, a Latin word meaning the wasting away of a body part, was often
used by physicians prior to Koch as a diagnostic term for tuberculosis of the lungs.

‘9 Bryder, 5—6.

2° Lerner, 2.

healthy in warding off the tubercle bacillus, but, more importantly, it would help already
active tubercular patients to become well again.

Although the initial sanatorium movement during the bacteriological era was
primarily instituted for the purpose of delivering a cure, by 1910 many sanatoria
increasingly adopted the goal of prevention.2| As the fear of contagion grew in the
twentieth—century, sanatoria, which were originally erected in remote locations for the
goal of providing fresh air, were increasingly seen as prime locations for quarantine,
where the tuberculosis patients could be isolated from the rest of society. With the goal
of prevention, sanatoria across the United States began to institute strict rules and
regulations for its patients with the goal of trying to shape the patient’s behaviors and
habits—they became places of strict education, where it was thought that patients who
had early stage tuberculosis could be taught how to avoid spreading their disease.

In addition, unlike the early sanatoria, which readily accepted advanced cases of
tuberculosis, the sanatoria of the late 19103 and early 19203 began favoring admission of
early (incipient) cases of tuberculosis. There was a two—fold rationale for this change in
admissions policy. First, medical officials thought that people who had incipient
tuberculosis posed a greater threat to society than the advanced cases. That is, they
believed that the people who had initial stages of tuberculosis and thus felt healthy posed
more of a problem because these healthy carriers would not believe that they were sick.

Medical officials worried that asymptomatic carriers would more likely be careless, and

 

2' Lerner, 25. In fact, according to Lerner, the Sixth lntemational Congress of Tuberculosis in
1908 encouraged sanatoria to take a more active role in the efforts of isolation and education in
order to better control the spread of the contagion.

not take the necessary precautions to prevent the spread of disease.22 Second, early
studies regarding the effectiveness of the sanatorium regime revealed that the highest
cure rates were among those who were in the early stages of the disease and that the
sanatorium had little—to—no effect on those who were admitted with moderate or
advances cases of the disease.23 So the sanatorium officials turned their attention toward
what they perceived to the more menacing yet hopeful cases of tuberculosis.

Along with the shifts in goals and patient populations, twentieth—century sanatoria
began to differ from the earlier sanatoria in treatment protocol, emphasizing complete
bed rest rather than promoting a balance between inactivity and exercise.24 Many of the
sanatoria in the initial years of the bacteriological era varied in their treatment
philosophies, especially concerning the issue of physical activity. Although most
medical directors prescribed rest for the initial week of a patient’s stay, there was little

consensus about how much physical activity a patient should be allowed to perform.

 

22 For more on why public health officials in the early twentieth-century viewed healthy carriers
as great threats to society, see Leavitt, 35ff.

2" For more, see Teller, 85—90 and Lerner, 22—30. Teller provides some interesting statistical
evidence that the medical community of the early twentieth—century used to assess the
effectiveness of the early sanatoria. For instance a study performed at the Mont Alto
Pennsylvania State Sanatorium in 1916 showed that out of 1,567 incipient cases, 261 were
considered cured, 558 “arrested,” 595 improved, 120 unimproved and 3 dead. (Teller, 83) In
addition, a longitudinal study was performed by the New York Loomis sanatorium in 1911 in
which medical officials surveyed the physical health of patients who were discharged from their
sanatorium between the years 1902—1905. Out of the 547 patients discharged, 61 percent had
died. Out of those 61 percent who had died, 17 percent were considered cured upon discharge
between 1902—1905, while 51 percent were considered arrested, and 72 percent improved.
(Teller, 89)

2‘ Bryder, 184—188. Bryder offers a different interpretation about the rise in rest therapy than the
one I advocate in this thesis. According to Bryder, the rise of the use of rest therapy can be traced
to the burgeoning field of surgery early in the twentieth—century. Given the fact that prior to the
1940s there were no drug therapies that could successfully eradicate the bacillus, surgical
procedures, which were believed to hasten recovery, flourished in the sanatoria. Writing
primarily about the British sanatorium system, Bryder argues that as the use of surgical
procedures increased, so too did the order for rest. Eventually, according to Bryder, “rest
was...prescribed even when surgery was not involved.” (Bryder, 184) But in the United States,
rest therapy was being advocated as a good in itself, regardless of surgery.

10

Some physicians adhered to the rule that a patient should rest only if he or she had a
fever, and that graduated exercise was the most beneficial treatment for those who were
asymptomatic. Other physicians, such as Dr. Alfred Loomis of New York and Dr.
Marcus Paterson (a prominent physician of the sanatoria system in Great Britain)
advocated work therapy, believing that a patient’s resistance was actually boosted by 5
heavy manual labor. 25 But by the 19208, a very prominent American physician named
Joseph Pratt began to persuade many of the sanatorium doctors that complete bed rest,
twenty—four hours a day for several months was a more effective treatment than work
therapy or only minimal rest.26 Pratt’s prescription for prolonged rest included even
those patients who were asymptomatic. Many sanatorium physicians and medical
directors followed in Pratt’s footsteps. For example, in 1922, Dr. Ernest Emerson who

directed the Rutland State Sanatorium in Massachusetts was prescribing a minimum four

 

2’ See Bryder, 184—188 and Keers, 90—94. Physicians in Great Britain believed that there was
much value in having sanatorium patients perform heavy manual labor. The work therapy
protocol required, for example, that patients be able to walk ten miles carrying spades and shovels
for digging. (Keers, 94) Many were convinced that work therapy had both social and
physiological benefits. First, many believed that work therapy was a good way to reinforce the
work ethic in the working classes. (Scale and Pattison, 50) In addition, following the work of
Marcus Paterson, many physicians held the view that through heavy labor, patients could release
their own tuberculin, a chemical byproduct which naturally increased their resistance to
tuberculosis (a view which later became known as the auto-inoculation theory). (Keers, 94) In
comparison to Britain, American physicians did not have the same enthusiasm for work therapy.
Bryder suggests that American physicians may have upheld the rest therapy due to the
competitive open marketplace. That is, more American doctors were concerned about their
professional status and thus promoted rest rather than work—a line of thinking based on the
assumption that patients would be more likely to accept rest and reject work. (Bryder, 186)
While the marketplace may have been a contributing factor, it does not account for the increasing
amounts of evidence that American physicians used to show that benefits of rest over work. Nor
does the marketplace argument take into account the social—cultural background of American
medicine during the nineteenth—century when consumption was treated primarily through rugged,
outdoor living. (Rothman, 131-161) That is, in America during the twentieth—century, the
consensus about the benefits of rest might have been a reaction against the failed nineteenth-
century prescriptions of extreme amounts of activity.

2‘ In 1923, Clive Riviere performed a study comparing the rest therapy as practiced by Pratt, and
the work therapy advocated by Paterson. Riviere concluded that rest therapy was superior. For
more on this, see Keers, 95.

11

months of rest for all sanatorium patients. And by the 1930s statistical evidence was
available which showed that patients (especially those with incipient cases) who
underwent the rest cure had higher cure rates than those who underwent work therapy.”
With such promising results, prolonged, complete bed rest eventually became the
dominant therapy of the American sanatoria.28

Confined to their beds for long periods of time, the patients who were admitted to
the sanatoria across the United States between the years of 1910 and 1940 had an
experience which was different from their predecessors or European counterparts who
were allowed to engage in moderate physical activity. The turn toward prolonged rest
therapy changed the image of American sanatoria. As Frank Ryan recounts,
The basic remedy was ‘bed rest’ in its most stringent form: 24 hours flat. Meals
were spooned to each patient by registered nurses, bed baths and the universal
bedpans were imposed on those. . .who looked and felt normal but who had
shadows—even small shadows—on their chest X—ray.29
Even those patients who were able—bodied enough to walk up to the institution’s doors
would not make physical contact with floor again until they had undergone months of
complete bed rest.30

This project is an account of what it was like to live in the American sanatoria

during the time period in which prolonged rest became the dominant therapy. As such,

this study’s primary focus is on the patient’s point—of—view. Its goal is to show how

 

27 Joseph Pratt, “The Evolution of the Rest Treatment of Pulmonary Tuberculosis,” The American
Review of Tuberculosis 50 (1944): 196. The sanatorium regime was never subjected to a large
scale scientific trial to test its effectiveness, so the records of how many patients actually
benefited from the sanatorium treatment are scant. But a more thorough investigation might be
able to further substantiate this point.

2‘ See Teller, 25 and Keers, 94.

29 Frank Ryan, The Forgotten Plague: How the Battle Against Tuberculosis was Won—and Lost
(Boston: Little, Brown and Company, 1993), 27.

3° For instance, MacDonald did not receive ambulatory privileges until 3 months after her
admission to the sanatorium. See MacDonald, 138.

12

patients who, for most part asymptomatic, experienced and endured their lot as patients
under the sanatorium regime; it explores the thoughts and emotions that they had as
subjects who were primarily confined to their beds, and relegated to a life of extreme
passivity. This study will map their experiences, explaining how they classified their
illness, how they reflected upon living in such confined quarters, and how they organized
reality. I will examine these patients’ hopes and feelings, to Show not only what they
thought but how they thought. 3 I

In this study, I argue that the rest therapy common to the American sanatoria
during the years of 1910—1940 had a great effect on the patients’ mental lives. Although
the prescription for rest was not physically invasive, it was psychically invasive.
Sanatorium patients paid a very high price for the hopes of a cure, that was unfortunately
rarely realized. They gave up their means of livelihood and lefl their families and fiiends
to live in the confines of the sanatorium. Cut-off from the outside world, they were left
with little to do but to “take the cure.” Most importantly, the sedentary lifestyle of the
rest cure promoted a deep feeling of isolation and alienation from the outside world.
Indeed, this alienation ran so deep that the patients began to perceive space, time and
their life plans (teleology) differently from when they were healthy.

In some respects, this project takes some initial steps towards filling a gap found

in the current historical literature relating to the topic of medicine. As historian Roy

 

3' Taking this approach to the sanatorium narratives, I have been influenced by two historians
who claim to practice what they call “microhistory.” For instance see Robert Darnton, The Great
Cat Massacre: And Other Episodes in French Cultural History (New York: Vintage Books,
1984), 3-4; as well as Natalie Zemon Davis, The Return of Martin Guerre (Cambridge: Harvard
University Press, 1983), 1—3. My understanding of microhistory has also been informed by Peter
Burke, ed., New Perspectives on Historical Writing (University Park: The Pennsylvania State
University Press, 1991), 1—23, 93—113.

13

Porter has pointed out, “we lack a historical atlas of sickness experience.”2 Porter
invites scholars to engage in a study of the sufferers’ role in history, to “lower the
historical gaze onto the sufferers,” to explore the other half of the doctor—patient
relationship. 33 Porter is responding to a tradition of medical history in which the
experiences of ordinary men and women had often been ignored. Prior to the 19705, the
story of medicine was primarily understood to be one of triumph, of new discoveries and
conquests, with physicians as the pivotal figures around which history revolved.34
Answering Porter’s call, this project will take a step toward moving the patients to the
center of the story alongside the physicians.35
This project, however, is not the first account of the experience of tuberculosis
from the patient’s perspective. Several scholars have studied narratives of those who had
tuberculosis in order to inform us about the devastating effects that the public health
movement and the sanatoria had on many patients’ lives. For example, in Below the
Magic Mountain, a book that recounts the anti—tuberculosis campaign in Great Britain,
Bryder dedicates a chapter solely to the patients’ view. In it, she discusses the
widespread stigrnatization with which tuberculosis victims had to contend, and she argues

that the sanatoria of the twentieth—century should be thought of as “total institutions,”

where patients were isolated from the rest of society “both geographically and socially.”36

 

32 Roy Porter, “The Patient’s View: Doing Medical History from Below,” Theory and Society 14
(1985): 192.

33

Porter, 192.
3‘ E. Richard Brown, Rockefeller Medicine Men: Medicine & Capitalism in America (Berkeley:
University of California Press, 1979), xi. See also Susan Reverby and David Rosner, ed., Health
Care in America: Essays in Social History (Philadelphia: Temple University Press, 1979), 3—4.
3’ Rothman, 3.

36Bryder, 200. Bryder gets the idea of total institution from Erving Goffman’s work on asylums.

l4

Using patients narratives, Bryder points out that some patients were treated as social
pariahs among their own families and, on the whole, shunned by the larger society.

Moreover, in her book, Living in the Shadow of Death, which explores how the
experience of having tuberculosis in America changed from the early nineteenth-century
to the twentieth—century sanatoria, Sheila Rothman gives an account of the sanatorium
experience that is very similar to Bryder’s. Rothman even equates the “total institution”
of the sanatorium to the “total institution” of prisons. And she draws this conclusion
directly from the patient narratives. As She writes, “to see the sanatorium from the inside,
from the perspective of the patient, is to see it in the first instance as an incarcerative
institution.”37 Rothman convincingly demonstrates the many ways in which sanatorium
life was like a prison by primarily focusing on the patients’ discussions of the sanatorium
admissions process, a time in which patients were treated according to the strictest of
protocols. For instance, following the rule book initiation, patients were often scrubbed,
stripped of many of their personal belongings (such as photographs, personal
medications, etc.) and escorted, usually by wheelchair, to a room, which they were made
to share with other patients.38

To be sure, thinking of the twentieth—century sanatoria as a “total institution” is a
helpful step toward understanding that patients were confined not only to a building, but
also to a “sick role” in which they had to adopt the sanatorium rules and regulations, and

stop living lives like healthy people would. But unlike Rothman and Bryder, I wish to

 

37 Rothman, 227. Rothman rightly points out that historians were by no means the first to make
the prison analogy, for many of the patients themselves write that they were treated like prisoners.
In doing so, she centers much of her discussion on patients like Marshall McClintock, who afler
receiving his rule book, claimed “I felt worse than ever. Like a prisoner.” See Marshall
McClintock, We Take to Bed (New York: Jonathan Cape & Harrison Smith, 1931), 145.

3“ Rothman 227—234.

15

shift the focus of the discussion to the rest cure. Prolonged bed rest was a therapy unique
to the American sanatorium regime of the early twentieth—century, and as such, it greatly
defined the perspectives of those who wrote about their experience. 39 A closer study of
the sanatorium patients’ day—to—day experiences, confined to bed, will reveal an even
deeper level of felt isolation, one that pervaded their daily thoughts, and shaped their
experience of reality. Looking at the narratives in this light, one can see the deleterious
effects that prolonged rest had on the patients’ psyches.

***

This study focuses on five people, all of whom were patients of the sanatorium
system and authors of their own autobiographies. All of these subjects were in the
sanatorium at a time in which the prolonged rest was used a therapeutic modality, and all
appear to have had incipient cases of tuberculosis.40 However, they underwent their

sanatorium stays in various parts of the United States. For instance, Isabel Smith, who

 

39 Prolonged bed rest is one important facet of the American sanatorium experience that Rothman
does not explore. Rothman claims that there was little consensus about how much rest and
exercise should be prescribed in the sanatorium. (Rothman, 206—207) But this was only true for
the first decade or so of the twentieth—century, for a significant amount of evidence suggests that
by the 1920s there was a growing consensus about the benefits of prolonged rest therapy
throughout the United States. Moreover, the fact that prolonged bed rest became a dominant
therapy in America sanatoria is a crucial element in interpreting the narratives that Rothman uses,
for a large majority of them were written in 19205, 19305 and 19405 and their authors write about
the experience of being confined to bed for long periods of time.

‘° Some of the narratives do not provide a clear timeline of their sanatorium experience. Will
Ross’ autobiography appears to be the earliest narrative. Based on the diagnostic tools that Ross
claims were used in his sanatorium (i.e. no X—ray diagnostics), I am inferring that he was in a
sanatorium sometime between 1910—1920. Likewise, Sadie Fuller Seagrave’s narrative also
gives no definite timeline, but I am assuming that she was in the sanatorium sometime prior to
1920. See Sadie Fuller Seagrave, Saints ’ Rest (St Louis: C.V. Mosby Company, 1918). Both
MacDonald and McClintock appear to have been in the sanatorium during the 19305. Lastly,
Isabel Smith was admitted in 1928 and underwent the longest stay out of the five
autobiographers. Smith was not released from Saranac sanatorium until 1949, when she received
chemotherapy treatment which cured her tuberculosis. Nevertheless, most of Smith’s
autobiography takes place between the years of 1928—1940. See Isabel Smith, Wish I Mght
(New York: Harper & Brothers, Publishers, 1955), xi, 213.

16

was diagnosed with tuberculosis while she was undergoing nurse's training in New York
City, was sent to the Saranac sanatorium system in upstate New York. Like Smith,
Marshall McClintock, who writes of both he and his wife’s experience with tuberculosis,
gave up his career in Cleveland, Ohio at the advice of his physician, to move his entire
family (he had one son) to Saranac.4| On the West Coast, MacDonald, a single mother of
two children, gave up her job as a secretary in a governmental agency to enter a
charitable state—run sanatorium just outside of Seattle, Washington. The final two
patients whom I examine come from the Midwest. Sadie Seagrave was admitted to a
state—run sanatorium in Iowa and Will Ross was a patient at a sanatorium in Stevens
Point, Wisconsin."2 These patients came from different walks of life: some were
married, others were Single, some had children, others did not. All of them, however,
were fairly well educated and apparently working middle class.43

Recounting the story of the patients who underwent the sanatorium regime of the
early twentieth—century brings with it some unique challenges, especially in trying to

reconstruct the patients’ worldview. For instance, what did these patients take to be the

 

" McClintock, 6—16.

‘2 Seagrave does not reveal the specific location of the sanatorium in which she stayed. It seems
probable that she was in a sanatorium in Iowa. See Seagrave, 12. Rothman supports this
conclusion that Seagrave was treated at a state—run Midwest sanatorium. See Rothman, 231.

’3 It should be noted that this study only tells a story of a very specific group of people, namely
that of white, middle class tuberculosis sufferers. However, it should be kept in mind that the
sanatorium experience in the United States did differ according to class and race. For instance,
those who could not afford private sanatoriums were often sent to overcrowded, urban, city-run
facilities. For more on this, see Rothman, 185—193. According to Barbara Bates, black
Americans who had tuberculosis and were admitted to a sanatorium suffered from higher death
rates than white Americans. In addition, black Americans encountered a more hostile
environment in the sanatorium than their white counterparts. While relatively little is written
about the American black experience in the sanatorium, Bates, in a chapter entitled “PS. I

Am. . .Colored,” provides a very insightfirl discussion about how the Pennsylvania sanatorium
system treated African Americans with tuberculosis. See Barbara Bates, Bargaining for Life: A
Social History of Tuberculosis, 1876—1938 (Philadelphia: University of Pennsylvania Press,
1992), 288-310.

17

causative factor of their disease? Why did they agree to go to a sanatorium in the first
place? Moreover, given the rigid therapeutic regime in the sanatorium, and the fact that
many of these patients were asymptomatic and therefore felt well, why did they stay?

Several of the narratives suggest that the patients’ understanding of tuberculosis
was informed by both humoral and bacteriological theories. Some, like MacDonald
admit to knowing very little about the disease. She writes, “I was almost thirty years
old,. . .but what I knew about tuberculosis, its symptoms, its cause and its cure, could have
been written on the head of a pin.”44 Although MacDonald grew up in a family that
believed that family history was the most important factor in disease causation, to a
certain extent, she was aware of the contagious nature of the disease. She recalls going to
movies and seeing public health announcements that counseled good hand washing, and
advised the public to cough into handkerchiefs so as to prevent the spread of contagious
diseases like tuberculosis.45 Still, almost every autobiography used in this study opens
with a detailed account of the narrator’s medial history, including his or her own believed
hereditary and constitutional predispositions to getting tuberculosis. For example, Ross
talks about how his mother had difficulty accepting the fact that her son had tuberculosis.
Ross quotes her saying, “ I just can’t see how it happened. . .There’s never been a single
soul on either side of the family so far as I know that ever had tuberculosis. Why should
it pick on you?“ That tuberculosis was caused by hereditary factors was still a widely
held belief in the early twentieth—century. In fact, even up until a 1939, when the

public’s understanding of tuberculosis was first measure by a Gallup poll, 50 percent of

 

“ MacDonald, 31.
‘5 MacDonald, 17—19, 31.
’6 Ross, 1-2.

18

those polled still thought that tuberculosis was inherited by birth, and 25 percent did not
know that it was contagious.47

In all likelihood, the public of the early twentieth-century was confused by
rapidly changing scientific discoveries; many lay people were probably not certain about
the mode of infection, or the best methods of treatment.48 Some may have willingly gone
to the sanatorium because it was the best hope for a cure.49 Or for those who understood
the contagious nature of tuberculosis, perhaps they went to the sanatorium so as to protect
their family and loved ones. To be sure, many patients did not want to go to the
sanatorium. And a significant number of patients left the sanatorium against medical
advice within the first few months of arrivals0 But as the fear of contagion grew within
the larger society and the public became more hostile to those with tuberculosis, many
patients may have wanted to go to a place, like the sanatorium, where people would be

more accepting of their disease.5 '

It: a: a:

In order to set the stage of sanatorium living, I begin this project with a brief
history of the sanatorium system. In chapter 1, I will explore more fully the medical
rationales behind the sanatorium regime of rest, diet and fresh air, many of which had
their roots in the pre—bacteriological era. More specifically, I will discuss several reasons

why the rest cure was so appealing to American physicians.

 

‘7 Teller, 63.

‘8 Teller, 57.

’9 In a 1939 Gallup poll, 86 percent of those polled believed that tuberculosis was a curable
disease. See Teller, 63.

5° For instance, according to Lerner, at the Firland sanatorium in 1916, 69 patients out of a total of
96 were discharged against medical advice. (Lerner, 29) Likewise, Rothman claims “anywhere
from 10—30 percent of sanatorium patients left within a month of arrival.” (Rothman, 245)

5’ Rothman makes this suggestion. See Rothman, 217.

19

After this introduction to the typical sanatorium regimen, the subsequent three
chapters explore how the patients reacted to this “new regime of living.” In chapter 2, I
examine the subjective side of the experience of confinement more deeply than it has
been in the existing historical literature. In describing the sanatorium as a place of total
confinement, previous historians have focused on the physical location and structure of
the institution, as well as the sanatorium personnel and rules which greatly restricted
patients’ personal autonomy and freedom. But keeping in mind the predominance of
prolonged rest in the American sanatoria, I will push the discussion of confinement
further, highlighting what the patients themselves thought of as the most immediate
barriers of their freedom—those of the room, bed, and the body.

Indeed, relegated to a singular bed, sanatorium patients experienced a kind of
encroachment of physical space. Indisputably their experience of “objective” space was
one of confinement and constriction; that is, the physical, measurable, three—dimensional
space in which they could move about was extremely small. However, as is evinced by
their narratives, patients experienced space not merely in objective terms, but also as
perceiving subjects. For example, conceiving of space in a more metaphorical way,
many patients claim that they felt that the “outside,” everyday world (which may have
physically only been a very short distance fi'om the sanatorium walls) stood at a great
distance from the sanatorium world which they inhabited. In fact, some patients claim
that the distance between themselves and their family grew to such an extent that they
eventually felt like foreigners among their next—of—kin. In addition, living a daily life in

a horizontal position, some patients indicate that their sense of spatial dimensions had

20

radically altered—that measurably short distances felt larger than what they were,
objectively speaking.

Thus chapter 2 will demonstrate that, from the patient’s point of view, objective
and subjective space were inversely pmportional in the sanatorium—as objective,
physical boundaries constricted, the subjective experience of space expanded. In a way,
it was as if sanatorium patients experienced the opposite phenomenon of what certain
people today call the “shrinking world.” That is, unlike those who claim that through
modern technology (like air travel and the Internet) the globe feels smaller than it did a
century ago, sanatorium patients experienced a kind of spatial expansion, for as they
continued to live in a state of confinement, they conceived of travel through relatively
small distances to be very difficult. Alrnost anything or anyone who existed beyond their
beds exceeded their grasp. To be sure, the actual size of thersanatorium or the “outside”
world had notchanged, but their subjective sense of the matter told them that as their
days in the sanatorium accumulated, so too did the distance between themselves and their
homes, families and friends.

Continuing to explore the effects of physical confinement on patients’ subjective
experience of their sanatorium stay, in chapter 3 I discuss how confinement effected the
patients’ abilities to make life plans. As we shall see, for a large part of their sanatorium
stay, the patients in this study all claimed to have felt well. This state of wellness often
allowed them to dream of their futures, of returning home, of pursuing their careers, or of
having a family. For, subjectively speaking, they felt well enough to accomplish these
goals. But despite their sense of well being, they were physically confined and not able

to act toward accomplishing their goals. Thus what precluding these patients from

21

realizing their life plans was not necessarily a grave state of sickness which was directly
impeding action, but rather a medical society which, in deeming them sick, confined
these patients to bed despite their subjective sense of well—being. I will argue that
ultimately this sense of well—being coupled with confinement to bed resulted in a kind of
a “teleological constriction,” for the only tangible and meaningful goal towards which
these patients could aim was discharge from the sanatorium. It was only after shedding
their sick roles as patients that they could resume the common teleological drives of
healthy persons.

Finally, in chapter 4, I address the influence that sanatorium confinement and the
phenomenon of teleological constriction had on the patients’ experience of time. In a
confined space, cut-off from the “outside” world, sanatorium patients write about the
feeling of losing touch with objective, measurable time. Thus, the patients’ days, weeks
and years were mostly dominated by a subjective sense of time—sometimes time would
seem slow, at other times fast. Moreover, I will argue that because of sanatorium
confinement, the passage of time became a dominant theme of many patients’ thoughts.
For some, time was the enemy, for they felt that they had too much “time to kill.” To
make matters worse, most patients had no sense about how long they would have to stay
in the sanatorium. Physicians, who were unsure of patient prognoses themselves, would
rarely discuss with their patients the projected date of discharge. Hence the patients’ one
teleological goal of discharge was quite opaque at best, and it is for this reason that many
patients became obsessed with the passage of time, for none of them knew how long it

would be until they would be able to return to their former lives in the outside world.

22

In trying to elucidate the patients’ experience of time, I rely on Thomas Mann’s
novel The Magic Mountain to supplement my interpretations of the patient narratives.
Although both Rothman and Bryder point to Mann’s novel as a perpetuator of false
conceptions about the sanatorium experience, it appears that, in regard to the particular
facet of subjective time experience, there is quite a bit of agreement between what Mann
writes and the narratives of American tuberculosis patients. While one should always use
caution in employing fiction to describe a real situation, Mann’s novel is nevertheless
located in the very real Circumstances of the sanatorium, and there are thus certain
aspects of the novel which can be helpful in historical interpretation.52

In all, this project explores how the given context of the twentieth—century
sanatorium and the predominant therapy of prolonged bed rest effected the patients who
endured it. Although the topic is narrowly focused on a particular time and a certain
patient population, I intend my readership to be broad. For not only will this project add
to the historical literature which already addresses the sanatoria of the early twentieth-
century, but it will also speak to current debates regarding the definitions of disease
(specifically those of a chronic nature) as well as the experience of sickness. For the
most part, the total confinement to the sanatorium molded the experience of those who
had tuberculosis in the early twentieth—century. As a work which primarily focuses on
the theme of the experience of sickness at a given point in history, this project will not
provide a definitive theory about the experience of sickness as such, nor will it be a
history about the rise or the triumph of the medical sciences. Rather it is story of
ordinary men and women whose stories reveal the cost that was paid for the hopes of a

cure.

 

’2 I would like to thank Steve Rachman for making this point clear to me.

23

CHAPTER 1
THE TRIUMVIRATE: REST, FOOD AND FRESH AIR

By the early twentieth—century, American physicians increasingly began to
prescribe a sanatorium regime of rest, diet and fresh air for their patients with
tuberculosis. In doing so, they rejected the common nineteenth—century therapy of
traveling to the Western plains of the United States and working the land as a means to
attain health. While the therapies of rest, diet and fresh air were rooted in a long tradition
of Western medicine, American physicians of the twentieth—century shaped the regime in
their own image and, most importantly for this discussion, radicalized the rest treatment.
The shift in the medical profession away from exercise toward the prescription of rest
occurred due to a variety of factors, among the most important of which was Koch’s
discovery of the contagious nature of tuberculosis as well as his influential notion of
disease “resistance,” a theory which prominent American physicians used to validate the

move toward prolonged bed rest in American sanatoria. 53

#434:

The prescription of rest and a diet of milk for tuberculosis can be traced back to

Galen who understood the disease to be a complication arising from the inflammatory

 

’3 This chapter by no means touches on all of the possible socio—cultural reasons why the rest
therapy became a predominate part of the American sanatorium regime of the twentieth-century.
A more in—depth study of this shift would certainly take account of economic forces which may
have influenced many physicians. For more information about market forces and physicians at
the turn of the twentieth—century, see Brown, 60—132. In addition, one would need to look more
closely at the fact that physicians of the early twentieth-century were vying for more power over
their patients. Rothman discusses this point in terms of a shift in the doctor—patient relationship
between the nineteenth—and twentieth—century. That is, in the nineteenth-century, physicians and
their patients enjoyed a more fluid relationship, for patients were understood to be essential to the
medical decision making process. But in the twentieth-century, with the rise of laboratory
medicine, treatment decisions were made solely by the doctor, and patients were expected to
comply. See Rothman, 179—252. Thus, from the physicians’ perspective, the sanatorium and its
requirement that patients stay in bed may have seemed like the perfect combination of institution
and practice with which to wield a great deal of power over their patients.

24

conditions associated with advanced forms of fever. More specifically, he understood
pulmonary tuberculosis to be an ulceration of the lung. Reasoning from analogy, Galen
thought “pulmonary ulceration demanded therapy similar to that employed to heal ulcers
of the body surface.” Yet the medication for the lung had to be something that could be
ingested.54 And apparently Galen thought that fresh milk was the best remedy for such
pulmonary ulcers. Along with milk, Galen was an advocate of inactivity, prescribing
“rest, restraint of cough and. . .a ban on visitors to eliminate the strain of conversation.”55

The Galenic model of treatment persisted in Europe throughout the following
centuries to greater and lesser degrees. For the most part, his dietetic regime was
followed for many centuries. But his theory of rest fell out of vogue in the seventeenth-
century, when exercise, such as horseback riding, was frequently prescribed. And in the
eighteenth—century, certain physicians advised tuberculosis patients to take up residence
in the country and to perform light work in gardens. By the nineteenth-century,
however, it became common to prescribe extended stays in closed, dark rooms and to
insist that the patient eat only very light, meat—free diets.56 At this time, clinicians also
began to formulate treatment regimes according to disease stages. Working from the
notion that tuberculosis was an “irritant” which should be treated by “counter—irritants,”
many physicians treated the initial “inflammatory” phase with an anti-inflammatory
regime of blistering, vomiting, purging and bleeding and the advanced stage of

“ulceration” with balsams and expectorants.57

 

5‘ Keers, 15. For more on Galcn’s theory of tuberculosis, see Scale and Pattison, 40.
5’ Keers, 15.

56 For more on the history of therapeutics for tuberculosis see Keers, 65—78, as well as Scale and
Pattison, 40—44.

’7 For more on the “irritant-counterirritant” theory see Charles Rosenberg and Morris J. Vogel,
ed., The Therapeutic Revolution (Philadelphia: University of Pennsylvania Press, 1979), 5—1 1.

25

Several notable physicians in the nineteenth—century opposed the common—day
treatments of bleeding and purging, and in doing so, they significantly influenced the
later sanatorium regimes of Brehmer and his successors. For example, writing an essay
on the treatment of pulmonary tuberculosis in 1840, Dr. George Bodington of Britain
argued that fresh, cold air was a better (and perhaps more humane) remedy than the
common counterirritants of such as digitalis, various emetics and shutting people in
closed, windowless rooms. He writes, “The application of cold pure air to the interior
surface of the lungs is the most powerful sedative that can be applied, and does more to
promote the healing and closing of cavities and ulcers of the lungs than any other means
that can be employed.”58 Bodington’s belief in the sedative effects of fresh air was well
received, for it was innocuous in comparison to the harsher pharmaceuticals of the day.
His treatment, however, was not completely benign, for in his mind, the colder the air, the
better. According to Bodington, “the cold is never too severe for the consumptive
patient. . .the cooler the air which passes into the lungs, the greater will be the benefit the
patient will derive. Sharp frosty days in the winter season are most favorable.”59

Another opponent of the overenthusiastic use of counterirritants of the
nineteenth—century was John Hughs Bennett of Edinburgh who believed that pulmonary
tuberculosis was caused “impoverishment of the blood,” and “exudations into the lung.”60
Thus Bennett believed that a diet high in fat was essential for nourishing the blood and

preventing further ulceration of the lungs. At the same time in France, S. Jaccoud who

studied medical pathology, argued for the therapeutic value of milk. Also believing that

 

5’ George Bodington, An Essay on the Treatment and Cure of Pulmonary Consumption (London:
Simpkin, Marshall, Hamilton & Kent,1840), 16—17, quoted in Keers, 68—69.

’9 Bodington, 16—17, quoted in Keers, 68—69.

6° J .H. Bennett, The Pathology and Treatment of Pulmonary Tuberculosis (Edinburgh: Sutherland
and Knox, 1853), 82 quoted in Keers, 71—72.

26

an increase in blood flow would help the tubercular patient, he maintained that milk
could work toward “diminishing the frequency and intensity of the cough, and after a
time has undoubtedly a sedative effect upon nervous and vascular excitability?“
Jaccoud also upheld the recommendation of rest and fresh air and felt that they were
perfectly compatible with his recommendation of drinking milk.

It is out of this long and rather complex tradition of therapeutics in the West that
Brehmer’s idea of the sanatorium arose. Unique to Brehmer was his insistence that
tuberculosis patients should live at high altitudes, for he believed that their metabolism
and circulation would increase once they were exposed to lower atmospheric pressure.
Believing that tuberculosis was primarily caused by poor circulation to the lungs,
Brehmer thought that a patient’s metabolism was further enhanced with a plentifirl diet
and graduated exercise. In his mind, complete rest was only suitable for patients who
were febrile. However, rest became a more predominant part of Brehmer’s system when
his physician-patient, Peter Dettweilcr, developed the concept of reclining cure chairs,
which were portable chaise lounges that could be used outdoors in protected verandas.
Although Dettweiler primarily developed the cure chair idea so that patients could benefit
from longer periods of fresh air, the fact that patients were ordered to remain in a chair
several hours a day meant that the sanatorium lifestyle became more sedentary by
default.62

At the time that the sanatorium idea was first introduced to the United States in

the 18805, many American physicians were still prescribing travel as a means to combat

 

6' S. Jaccoud, The Curability and T reatrnent of Pulmonary Phthisis (London: Kegan Paul, Trench
& Co., 1855), 190, quoted in Keers, 74—75.

62 For more details on Brehmer’s sanatorium regime, see Rothman 194—195, Keers, 76—77 and
Pratt, 1932, 64—65

27

tuberculosis. Until the sanatorium gained ascendancy, many tubercular men who lived in
the cold, dank, wet environment of New England traveled to more health—conducive
(often warmer, dryer) climates and labored in the open air. Early in the nineteenth—
centmy, many men went on sea voyages to improve their health. But as the century
progressed, many consumptives, known as “health-seekers,” traveled West to the open
plains to live a more rugged life of riding horseback, eating buffalo meat and sleeping
outside in the open air.63
It was in era of “health—seekers” that Dr. Francis Trudeau built the first American
sanatorium and Dr. Paul Kretzschmar, a patient of Dettweiler’s, delivered several papers
advocating the Brehmer—Dettweiler sanatorium system. Kretzschmar adamantly opposed
the America prescription of out—of—door living. First, he argued that to promote a life
outdoors among other healthy people, was to disregard Koch’s new theory of contagion.
Allowing Americans to travel freely from state—to—state meant that the contagion traveled
with them which increased the potential spread of disease. Second, he thought that
American physicians who allowed their patients to perform heavy labor ignored the
important relationship between the disease and lowered resistance. Following Koch’s
theory of resistance, Kretzschmar believed that the sanatorium regime of rest was better
at strengthening the patient so that she could resist the bacillus. Finally, in advocating the
Brehmer—Dettweiler regime, Kretzschmar maintained that patients required physician

supervision in order to get well."4

 

‘3 For more on sea-voyagers and health—seekers who traveled West, see Rothman, 13-57, 131-
161.

6‘ Much of the information and interpretation of Kretzschmar’s arguments come from Rothman,
196—198.

28

Similar in thinking to Kretzschmar, Trudeau built the first American sanatorium
system in Saranac, New York, based on the belief the best treatment for tuberculosis
required improving a patient’s resistance through an abundance of food, invigorating
climate and rest. Trudeau did not prescribe prolonged bed rest, however. Rather, he
maintained that a balance of light exercise and rest was the best remedy for a cure,
especially for those patients who had “inactive” cases of tuberculosis. Nevertheless,
when compared to his European predecessors of Brehmer and Dettweilcr, Trudeau was
much more cautious about prescribing exercise. In a letter to a fellow physician, Trudeau
is quoted as saying, “the fact still remains that when a tuberculosis process shows any
degree of activity, rest is the safest plan to follow. I know I have hurt nobody by rest, but
I am quite sure I often have by allowing-them to exercise.”65 Trudeau thought he had
learned some important lessons about rest from the new surgical techniques of the day.
At an Association of American Physicians in 1900, he delivered a paper in which he said,
“Surgery has taught us that activity of a part affected with tuberculosis always tends to
aggravate the disease and render it progressive. A tuberculous joint may often be cured
by simple immobilization, while it will go on to destruction if the patients be allowed to
use it at will.”66 For Trudeau, rest was the safer route to take so as to avoid any
aggravation of a patient’s condition.

Although the amount of activity that a tuberculous patient should undertake was a
subject of dispute among American physicians around the turn of the twentieth-century,

several prominent physicians came to a consensus by the 19205 that prolonged rest was

 

6’ This is how Pratt recounts the words of a letter that Trudeau sent to Pratt in 1900. See Pratt,
“The Development of the Rest Treatment in Pulmonary Tuberculosis,” 65—66.

‘6 Trudeau quoted in Pratt, “The Development of the Rest Treatment in Pulmonary Tuberculosis,”
65.

29

more beneficial than exercise. This consensus started to form when physicians and
researchers at the Trudeau sanatorium began publishing studies purporting to show that
rest was better than exercise at building up a patient’s resistance. For example, in 1917,
Dr. Kinghom of Saranac performed a comparative study between the rest cure at Saranac
and work therapy at the Brompton sanatorium in England. His results showed that
“patients who undergo prolonged and intensive rest treatment do not tend to relapse?”
Moreover, in 1916, Dr. Joseph Pratt, who was endorsed by Trudeau, delivered an article
at the National Tuberculosis Association and claimed that “when the average period of
rest treatment was increased from seven weeks to four months, the disease was arrested
in a distinctly larger percentage of cases.”68

The fact that these results came from physicians associated with Saranac had a
significant impact on the rest of the United States, for Trudeau’s sanatorium was
repeatedly looked upon as the model institution for new and upcoming sanatoria in
America. By 1919 several of the largest, most prominent sanatoria began increasing the
length of time that patients were order to stay in bed. Moreover, an increasing number of
sanatoria medical directors began to prescribe rest for even their asymptomatic patients.
This shift in treatment protocol can be seen in a 1919 questionnaire that Pratt sent to

several of the largest sanatoria across the country. When asked how long they would

keep afebrile patients with a positive sputum sample in bed, the Glendale County

 

‘7 Kinghom quoted in Pratt, “The Development of the Rest Treatment in Pulmonary
Tuberculosis,” 67.

68 Pratt, “The Evolution of the Rest Treatment of Pulmonary Tuberculosis,” 194. A further line of
investigation about the rest cure in America would be to study the influence of Dr. Silas Weir

Mitchell, an American physician who developed and prescribed the rest cure for hysteria in the
nineteenth-century.

30

Sanatorium in Minnesota answered 6 weeks, the Westfield State Sanatorium replied with
8 weeks, and the Rutland State Sanatorium in Massachusetts said 16 weeks.‘59

By the 19205, many sanatorium physicians were advising all of their incoming
patients to begin a regime of “complete rest,” which often meant rest in its most extreme
form. For example, the physician who admitted Will R055 to the River Pines Sanatorium
in Wisconsin greeted him with the following instructions, “I want you to lie. as nearly
motionless as you can manage. Don’t even think if you can avoid it. Once you have
gotten yourself thoroughly disciplined to rest the way I want you to, you will be well
started on the road to a cure.”70 Rest did not mean taking a mid-afternoon nap, or even
maintaining a reclined position twenty-four hours a day. Rather, rest in the sanatorium
meant being horizontal, without so much as a thought, a sound, or a twitch.

In the Washington State Sanatorium, all entering patients were instructed on how
to be as sedentary as possible. MacDonald, a patient of the Washington State Sanatorium
in Firland (which she called “The Pines”) writes, “when we entered The Pines the Charge
Nurse instructed us never to pick up anything from the floor. If we dropped something
we were to wait for a nurse...”71 But simply lying in bed was not resting either, for
resting was done with the mind as well as the body. Not only were patients discouraged
from deep breathing, talking, or singing in order to avoid overtaxing the lungs and heart;

they were also discouraged from becoming mentally fatigued. In many sanatoria, writing

 

69 Pratt, “The Development of the Rest Treatment in Pulmonary Tuberculosis,” 68. The specific
question that Pratt posed to the medical directors of these sanatoria was stated as follows: “How
long would you keep in bed a patient with pulmonary tuberculosis who presents the following
features on admission? No fever, pulse slightly accelerated or normal, no loss of strength, but a
few pounds underweight, slight cough with positive sputum, dullness and tales at the top of one
lung.”

7° Ross, 86.

7' MacDonald, 122.

31

and reading were often restricted for the first couple weeks of every patient's stay.
Patients were advised to do everything and anything in their power to keep their pulses as
low as possible. Or as MacDonald described it, “the nearer a comatose state”
tuberculosis patients could approximate, the better their chances of recovery.72

The more passive a patient was, the better, for the medical community believed
that it was only through inactivity that the tuberculosis “bugs” would become dormant.
The advice of researchers and physician like Koch, Osler, Kretzschmar and Pratt had
reached many sanatoria across the United States, and many physicians readily accepted
the theory that activity was in direct conflict with the goal of walling off the bacillus in
the lungs. Not only did certain physicians believe that rest would build up resistance;
they also thought that prolonged “bed re‘st...allowed for the rebuilding of muscle, the
gaining of strength, and the healing of diseased lung tissue?”

In order to communicate the importance of rest to their patients, physicians at
Saranac began to adopt a metaphor to describe the difference between their more
compliant, sedentary patients and their noncompliant, restless patients.74 Advising his
patient, Isabel Smith, on how to rest, Dr. Francis Trudeau claimed that “all my patients
are either cows or antelopes....Being an antelope’s OK. when you’re well, but it’s bad
when you’re sick....Even in bed people can be antelopes, jumping up to look out the
window, wriggling around, talking and laughing too much.”75 Like cows, the compliant
patients who rested were understood to be reserving their energy and saving it for the

natural healing process. As Trudeau described it, “the ideal tubercular patient is like a

 

72 MacDonald, 84.

73 Lerner, 25.

7‘ McClintock, 36 and Smith, 32.
75 Smith, 32, emphasis in original.

32

cow. You should be flat on your back in bed twenty—four hours a day, never getting up,
never writing, never reading, never even thinking.”76 On the other hand, the active,
antelope—like patient was thought to be in danger of never being cured, for it was
believed that any activity which increased the heart rate would have the effect of
“wash[ing] out more poisons from the tuberculosis sore.”77
While many sanatoria across the country prescribed bed rest for the initial months
of a patient’s stay, the amount of activity that a patient was allowed to undertake in bed
varied slightly from sanatorium to sanatorium. In Ross’ sanatorium, for instance, there
seemed to have been no restrictions on reading and writing while in bed."8 But a more
representative sanatorium regime is found in MacDonald's account.79 According to
MacDonald, the Washington State sanatorium put every entering patient on strict bed rest
for at least one month, which meant that a patient was restricted from all activities,
including reading and writing. While on strict bed rest, a patient's day would simply
revolve around the sanatorium—wide schedule of sleeping time and meals, all of which
were served in bed.80 If a patient was considered to be improving medically (that is, if she
had a consistently normal body temperature and Showed signs of weight gain) at the end
of one month, the patient would be granted “up time,” which meant that the patient would

be allowed to perform minimal activities, such as fifteen minutes of daily reading or

writing, or taking care of one's personal hygiene. The allotted time and level of activity

 

7‘ Smith, 32.
77 MacDonald, 128.
7' Ross, 85. One possible reason why Ross’s regime was not as strict as MacDonald’s was that
Ross was in the sanatorium sometime between 1910—1920, when prolonged bed rest was just
becoming a popular therapeutic regime.

By representative, 1 mean in regards to the other autobiographies that I am looking at in this
study. All of the other autobiographers mention writing and reading restrictions.
8° Depending on the sanatorium, the duration and frequency of rest period would vary. Typically
rest periods were scheduled from two—three hours, two—three times a day.

33

would be increased as the patient improved, until eventually (usually after a minimum of
three months) a patient would be given ambulation privileges.“
While prolonged bed rest continued to be a predominant part of the American
sanatorium regime, most sanatoria still continued with the tradition of a prescribing an
abundance of food and plenty of fresh air. By the twentieth—century, a diet of foods rich
in protein was thought to help build a patient’s resistance, providing the body with the
needed strength to ward off the tuberculosis germ. As a physician explained it to Ross,
“when you’ve got tuberculosis, and especially when you’re running a temperature, it’s
tearing you down as fast as if you were digging ditches all day and maybe faster.”82 In
other words, the bacillus was believed to be taking up very precious energy stores and it
was only through large quantities of food that the energy could be restored. According to
Elizabeth Mooney, who recounts her mother’s experience in Saranac, the diet was based
on the rule that the patient was eating for three—“once for yourself, once for the germs,

”83

and once to gain weight. The kind of diet that was needed to accomplish such goals

was one of “six glasses of milk daily, six raw eggs, cream soups, Hollandaise, [and]

chocolate cake with icing.” 8"

 

8' MacDonald, 142.

‘2 Ross, 91-92.

'3 Elizabeth Mooney, In the Shadow of the White Plague (New York: Thomas Y. Crowell,
Publishers, 1979), 41.

54 Mooney, 42. Rothman concurs with Mooney’s description, reporting that at the Trudeau
sanatorium “patients received three full meals a day and a glass of milk every four hours.”
(Rothman, 204) It is interesting to note that while milk was being used as a staple of the
tubercular diet, at the same time, the bacteriological camp was divided about the infectiousncss of
bovine tuberculosis. According to Scale and Pattison, Koch declared in 1901 that bovine
tuberculosis was harmless to humans, which had the effect of greatly hampering the movement
for the pasteurization of milk. Those that opposed Koch’s simply did not have the power or
authority to easily override the influence of his theory. Because of this, “the effective safety of
milk was delayed until World War II, with the result that generations of children were...exposed
to the risks of bovine tuberculosis.” (Scale and Pattison, 48)

34

Along with complete rest and ample food, patients were instructed to get plenty of
fresh air, for it was believed that direct exposure to air, especially cold, winter air,
lowered the workload of the lungs which thus hastened the healing process.85 Trudeau,
for example, instructed his patients to remain in the open air eight to ten hours a day.86
Fresh air was understood to be such an essential element to rehabilitation that in Saranac
the architecture of the town took on a wholly unique appearance. For instance,
McClintock describes his first impression of Saranac while driving his wife, Helene,
there for treatment:

We passed a few houses, houses such as are seen only in Saranac, houses with

porches on every side, at every comer, porches tacked precariously on the sides,

jutting out from second and third floor rooms....and on all of them were men and
women lying in long reclining chairs....silent and unmoving, a few reading, but
most just lying there silent and tmmoving.87
Peculiar to Saranac’s sanatorium system were cure cottages, small home—like buildings in
which only a few patients would reside. And "visually, structurally speaking, the cure

porch...is what ma[de] a cure cottage a cure cottage."88

Thus patients who were not
restricted solely to bed rest, would receive their fresh air treatment in the Dettweilerian
cure chairs wrapped in heavy horse blankets, with gloves, hat and woolen socks during

the winter months.89 But as larger institutions were constructed and rest therapy became

 

8’ Lerner, 25.

8‘ Rothman203.

8" McClintock, 23.

’8 Philip L. Gallos, Cure Cottages of Saranac Lake: Architecture and History of a Pioneer Health
Resort (Historic Saranac Lake, Saranac Lake, 1985), 7. Gallos provides a thorough discussion of
the evolution of the porch and the various kinds of porches which were built in Saranac for the
purpose of fresh air treatment. Gallos confirms McClintock’s description of “tacked” on porches,
explaining that cure porches were often added on to preexisting homes, including second-story
sleeping porches (Gallos, 9). For a more detailed discussion (including visual illustrations and

photographs) about cure porches and their various designs, as well as the cure cottage system in
Saranac, see Gallos, 5—17.
'9 Lerner, 25.

35

a more prevalent form of treatment, the “down-patients,” or those who were confined to
complete bed rest, would often receive their fresh air simply from open windows—a
situation which often made for uncomfortable living quarters, with “ice—cold, fog—
dampened sheets.” 90
For many patients, the order to rest, eat and take in fresh air was welcomed, at
least initially. Many of the new arrivals were very sick and were often working and
raising children up to the time of their admission. Prior to being admitted to the
sanatorium, MacDonald writes of her persistent colds (six in one winter), sharp pains in
her lungs, and a heavy feeling over her heart, while working full-time and raising two
children by herself. She was so fatigued at one point that she writes, “I began getting up
in the morning feeling dead tired after dressing...I would feel like going back to bed
instead of straining at the leash to begin the day’s activities.”91 Likewise, admitted with a
fever of 103 degrees, Ross reports that for his first four or five days at the sanatorium, he

”92 Moreover for others, the order to rest was a validation of

“slept almost continuously.
their failing state of health. “Rest!” Smith exclaimed after her initial diagnosis, “It felt so
good to lie down that for a moment I was actually glad. No one would call me lazy now
or laugh at the pain in my chest.” The diagnosis of tuberculosis had the effect of making
a patient’s symptoms more real, not only for the patient herself, but also for the others
around her.93

But once they were well—rested and recovered from symptoms of fatigue, the

patients in this study found living in the sanatorium a difficult struggle. Once they

 

9° MacDonald, 59 and Seagrave, 161.
9' MacDonald, 3o.

92 Ross, 84.

9’ Smith,17—18.

36

confronted the reality of having to live every day confined to bed despite the fact that
they often felt well, these patients fought feelings of restlessness, isolation and
confinement. As several social historians have pointed out, the reality of the American
sanatorium experience cuts through any romantic depictions of tuberculosis and the life
of those who fell victim to it. From the viewpoint of ordinary sufferers, tuberculosis was
an unwanted disease that had the potential of permanently disrupting the lives they led as
healthy persons. Leaving behind the things that gave meaning to their lives—their jobs,
homes, friends and families—patients in the sanatorium led a wholly new life of docility,

confined by a new set of house rules which were not of their own making.

37

CHAPTER 2
“AN ISLAND OF ACTIVITY”: SANATORIUM SPACE

Most recent histories of tuberculosis treatment in the twentieth—century do not
portray the sanatorium movement in a very positive light. Skeptical that sanatorium
treatment played any role in the decline of tuberculosis in Great Britain during the first
few decades of the twentieth—century, Bryder describes the sanatoria as “total
institution[s], sharing features with other institutions such as prisons, schools, lunatic
asylums, and hospitals,” where patients were treated like “children, incapable of making
decisions for themselves.”94 In a similar vein, Rothman argues the typical American
sanatorium was essentially an “incarcerative institution,” “a waiting room for dea ,” a

place where “profound unhappiness, disappointment, and despair were the dominant

emotions.”95

Both Bryder and Rothman discuss sanatorium space in terms of confinement,
claiming that patients were not only geographically cut-off from society but also socially
isolated and controlled.96 Sanatorium patients, according to these accounts, had to endure
multiple layers of confinement from social stigmatization to domineering medical
personnel who strictly enforced rules which regulated almost every minute of a patient’s
life. In the end, both authors conclude that often the sanatoria treatment regime ended up
resembling behavior control more than therapy. But, interestingly, neither Bryder nor
Rothman address the most extreme form of restriction: confinement to a bed.

The fact that prolonged bed rest was a common therapy to most American

sanatoria is crucial, for it exerted the greatest influence on the patients’ day-to—day

 

9‘ Bryder, 200, 205.
9’ Rothman, 226—227.
9‘ Bryder, 200—201 and Rothman, 227—234.

38

experiences. To be sure, patients write about the same layers of confinement that several
historians have discussed (i.e. the building, the staff, the rules). Yet their autobiographies
predominantly revolve around their beds, for the hospital bed was not only a place where
they spend most of their days, but it also played a crucial role in determining their states
of mind. While some patients might have physically benefited from rest, the mental cost
of such a treatment was great. Because of prolonged bed rest, many patients suffered
from extreme degrees of anxiety and helplessness. In addition, prolonged rest had the
effect of altering the patients’ subjective notions of space to such an extent that they
became more dependent on their beds; many of them became quite fearful of traveling
relatively short distances. Moreover, patients on such a radical regime of prolonged bed
rest could no longer relate to the world that stood outside the sanatorium walls. Because
of their passive lot in life, they could not help but to be self—absorbed, which, in turn, left
them with a deep sense of solitude and isolation.
The Confines of the Sanatorium

Because of the supposed therapeutic benefits of fresh air, many of the early
American sanatoria were built in desolate areas, away from urban centers. The chosen
sites for sanatoria were frequently small farming communities, such as Saranac and
Rutland, Massachusetts.97 Often, the name of a sanatorium reflected its physical
surroundings, especially if it was in a desirous location, guaranteeing pristine air. For
example, the F irland Sanatorium, where MacDonald was admitted, was named after the
forest of fir trees which ensconced the attractive Elizabethan, Tudor—style building where

the bed rest patients would reside.98 Similarly, Ross took his cure at the River Pines

 

’7 Rothman, 217—8.
9‘ Lerner, 23-25.

39

Sanatorium in Stevens Point, Wisconsin, a thickly wooded area 150 miles north of
Milwaukee. Because of the remoteness, a move to a sanatorium usually required that a
patient undergo a significant amount of travel either by car or train, making the transition
from home to sanatorium a significant, if not also a frightening event. Once they were in
the sanatorium, patients were geographically cut-off from the rest of society.99

Inside the sanatorium walls, patients did not necessarily experience the serenity
and peacefulness that the surrounding environs promised. Rather, once inside, patients
often encountered a wholly foreign and unwelcoming environment. Recounting her first
impressions of the Firland sanatorium while sitting in a creaky wooden wheelchair,
MacDonald describes being transported down a “long, draughty, pale green hall, each
side of which was partitioned off into rooms.” As she peered in each room she saw
“white—covered single beds... and in each bed a head was raised,” staring back at her.'00
She describes the ward to which she was assigned as spartan, “and square...[with] four
casement windows, curtainless and blindless and opened wide. In each comer of the
room was a bed, a bedside stand and a chair.”'°' As MacDonald puts it, she was
“deposited” in the bed in the southeast comer of the room, which was flush to the

easterly—facing windows. '02

Not only were patients physically confined to a building, they were also restricted
to a set of social rules and regulations which controlled virtually every aspect of their
daily lives. For instance, within the first couple hours of their arrival, most patients were

forced to sign a rule book, demonstrating their willingness to conform to a seemingly

 

99 Bates, 69.

'°° MacDonald, 53.
'0' MacDonald, 55.
”2 MacDonald,73.

40

endless list of sanatorium do’s and don'ts. McClintock describes receiving his very own

rule book which had his number on it—8027:
The book was fill of rules, lots of rules. Everyone must be out of doors...between
nine and twelve thirty and between two and five. . . .No one could leave the
grounds and go to town....The rules seemed endless?”
In accordance with McClintock’s account, Seagrave estimates that there must have been
as many as one thousand rules listed in her book.104 Most of the sanatorium rules were
instituted to prevent the spread of the contagion. For instance, the most important rules
were “not sneezing in each other's faces, holding a piece of gauze before the mouth when
coughing,” and expectorating only into a sputum cup.105 Other rules, though, were
instituted to maintain order within the sanatorium walls. For instance, contact between
the sexes was strictly prohibited not only because pregnancy was believed to be
detrimental to the female tubercular’s health, but also because such socialization was
seen as a potential disruption to the sanatorium regime.106
In the hopes that they could control the spread of disease, sanatorium officials
also restricted family visitation. According to the rule book at the Firland sanatoriunr,
MacDonald was only allowed to see her children once a month for ten minutes and the
other members of her immediate family twice a week for two hours.107 But even when
family members would come to visit, it was marked by a great degree of awkwardness
and sadness, resulting from the ubiquitous fear of spreading the contagion to a loved one.

Upon the first visit of MacDonald’s two daughters, the one daughter, with tears in her

eyes, exclaimed to her mother, “I would like to kiss you....[but] the nurse said that we

 

”3 McClintock, 145.
'0‘ Seagrave, 50.
105

Seagrave, 50.
'06 Rothman, 236.
”7 MacDonald, 51.

41

couldn’t even touch your bed.”'°8 Likewise, McClintock recounts bringing his young son
(Marco) into the sanatorium to see his tuberculosis—stricken mother as a heart—wrenching
experience: “Helene did not touch him [Marco], did not kiss him. She was afraid she
might cough.”109 Even intimate physical contact between husband and wife was
discouraged—according to their rule book, the McClintocks, for example, were only
allowed to kiss through gauze.

In addition to confinement to institutional walls and regulations, many sanatorium
patients lived in cramped quarters. Seagrave, in a Midwestern state sanatorium, describes
undergoing the open-air treatment in which there were “seven beds on...the side porch.”
In order to give the reader a better sense of how much room there was, Seagrave adds, “if
I had seven arms I could punch everyone at once.”l ‘0 Likewise, MacDonald lived out
most of her sanatorium stay in a room with three other women. In fact, in the Firland
Sanatorium, a patient was in the company of several other patients even during her
bathing time.l ”

While certain sanatoria dimensions might have been very restrictive, the order to
remain in bed was by far the most confining part of the treatment regime. Not only was it

limiting in a physical sense, but it also created a context which fostered mental

 

"’8 MacDonald, 143.

'°° McClintock, 112.

"0 Seagrave, 48.

111 It should be noted that the living space that patients enjoyed varied slightly according to each
particular institutions. The physical layout and construction of sanatoria across the United States
often varied according to whether it was a state—run or private institution. For instance, when it
opened in 1914, the Washington State Firland Sanatorium contained beds for 150 adults and 25
children. See Lerner, 24. In comparison to the private Saranac cottages which housed only 3—4
people, F irland was a rather large institution. As a result, patients of the state—run sanatoria often
write of living in close quarters. But nonetheless, patients in private sanatoria often stayed in
rooms by themselves, leading them to feel a great deal of loneliness, for they lamented the fact
that they only had contact with nurses and doctors. See, for instance, Ross 85, 107.

42

boundaries. From the perspective of those patients who underwent the treatment of
prolonged rest, the bed was the most immediate barrier which precluded them from
taking on a more healthy mindset of feeling connected to their loved ones and the outside
world and enjoying certain pleasures of individual freedom.
The Life of the Horizontals

For sanatorium patients, the hospital bed was the place where one would spend
hours on end “taking the cure? In essence, it became the border of one’s own personal
space. Some patients likened it to a place of residence. As Ross writes, “my bed was my
castle and I was cautioned to stay in it.”l '2 Not only were patients confined to a
particular building, in a desolate area away from their families and society as a whole, but
they were ultimately confined to the smaller area of a singular bed. Depending on the
treating physician and the rules of the particular sanatorium, the degree of movement and
the activities allowed within the confines of one’s bed varied, but not to a great degree.
Referring to his bed as an “island of activity,” Ross suggests that the protocol to rest was
not as strictly enforced as it was in other sanatoria.l '3 However, for some patients who
endured strictly—enforced rules of complete passivity, the bed became more of a foe than
a friend. Smith describes her bed as an obstruction of her will to move with the “blankets
tucked in all the way up on both sides, forming a tight enchOpe in which [one] was held
like a vise.”l '4 Taking the little liberty that she had, Smith writes, “I turned my head

from side to side, rebelling at the feeling of confinement.”1 ’5

 

”2 Ross, 85.
"3 R055, 100.
"‘ Smith, 29.
"5 Smith, 29.

43

Lying in a recumbent position on a daily basis, sanatorium patients naturally had a
very limited and peculiar perspective of their physical surroundings. Describing the daily
life of someone who spends the entire day in bed, the sanatorium autobiographies often
focus on mundane objects that only a person who is in a horizontal position would hold in
his of her field of vision. For instance, a common object of description is the ceiling.
Apparently feeling the need to explain his frequent excursive musings, Ross writes,
“when you are lying on your back, the easiest place to look is up.”116 He continues, “I
lay for a long while staring up at the ceiling. There wasn’t much on the ceiling to look at
but a neat row of boards painted a neutral gray....That curious little break on the board
overhead must have been where the carpenter’s plane had slipped.”1 '7 At times the
ceiling claimed so much mental concentration that some patients became incensed with
their obsession with such mundane things. Indeed, patients like Smith understandably
became resentful of her monotonous surroundings, “[my] room...looked lonely and
bare...[with] many of the familiar objects which had made my former dwelling into a

home...stowed out of sight. I...lay [in bed], staring at the ceiling, hating each and every

crack ”I 18

The day—in, day—out scenery of the same four walls and the same ceiling became
so monotonous that even the slightest change seemed monumental. MacDonald
provides her readers with repeated and very detailed description of her view out the
window from the second floor where she “could just see the tip of one of the poplar

[trees]....[and] the sky was a dirty white...”119 One day when she was looking at this

 

"6 Ross, 87.

"7 Ross, 87.

"3 Smith, 70.

“9 MacDonald, 73.

44

typical scene out of her window, MacDonald writes, “while I watch [the poplar tree], one
small leaf let go and dropped limply through the misty air. Compared to the hospital it
seemed like an act of hysterical activity.”lzo
Living life in a horizontal position was not only a drudgery, but it also had
disturbing effects on the patients' mental well-being. First, assuming such a position
compounded their feelings of helplessness and dependency.121 “Everything [about the
sanatorium]? Smith writes, “seemed designed to lull me into a state of passive and
disinterested acquiescence. . ..”'22 She further explains that it was the bed rest regime in
particular that made taking on an active role in her care virtually impossible: “plump
pillows, soft blankets and the deep comfort of an innerspring mattress mean snuggle, not
struggle. They undermined, rather than strengthened my will to participate. . ””123 While
the general consensus at this time was that patients should be compliant, passive
recipients of a physician’s medical decisions, living horizontally only helped to reinforce

the patients’ non—participatory role in their own health care?“ Confined to bed,

sanatorium patients assumed a submissive position. And because they were told that any

 

120 MacDonald, 75.

121 It is interesting to note that although there is evidence that a significant number of patients
discharged themselves against medical advice, none of the autobiographers in this study seem to
have contemplated such a course of action themselves. The description of “living horizontally” is
influenced by Thomas Mann, The Magic Mountain, trans. John E. Woods (New York: Vintage
lntemational, 1995). Throughout the novel, the leitrnotif of “living horizontally” takes on several
different layers of meaning. The character of Settembrini is the one who facetiously coins the
phrase “horizontals,” mocking the unequivocal conformity of those who take the rest-cure,
willingly obeying sanatorium rules. In his eyes, assuming a horizontal position ultimately meant
taking on a certain kind of submissive role. See Mann, 71.

'2’ Smith, 58.

‘23 Smith, 58.

124 With the rise of laboratory medicine and new esoteric knowledge that only doctors could
access, patients went from active participants in medical decision-making during the better part
of the nineteenth—century to passive recipients of care by the twentieth-century. In fact patients,
such as Seagrave, were repeatedly told not to “rely too much on [their] own judgment.”
(Seagrave, 37) For more on the shift in doctor-patient relationship from the nineteenth— to
twentieth-century, see Rothman 179—197.

45

physical movement or usage of the lungs was harmful to their health, most patients
remained motionless and silent; in effect, they were dissuaded (whether directly or
indirectly) from asserting themselves. Indeed, the autobiographers of the sanatorium
experience concur that being confined to a bed and restricted from virtually all activity
led them to adopt an unwanted, passive stance toward the world—one in which each
patient had to struggle to maintain his or her will to live.

Besides it symbolizing a position of submission, living horizontally also served as
a reminder of the possibility of one’s own demise.‘25 Although death was often a taboo
subject in the sanatorium, several of the autobiographers still admit that they would often
experience a kind of existential angst, despite the fact that, for much of the sanatorium
stay, they had a general sense of physical well—being. But lying in bed 24—hours a day
and being told that they were sick with a grave disease eventually took its toll. The dark
foreboding feelings about death and dying surfaced and were most pronounced when the
patients were on strict bed rest.126 Ross reveals one moment of extreme fear that

occurred during one of his rest periods on a cure porch. He writes, “On my narrow porch

 

12’ This idea is influenced by Mann. Towards the middle of The Magic Mountain, Mann gives the
metaphor of “living horizontally” an additional meaning of death. Describing death as the
permanent “horizontal form of existence,” one gets the sense that, in a jocular way, Mann sees
sanatorium life as a rehearsal, where patients are practicing their supine positions of rest, getting
it just right for opening night, or, better yet, for the final day of judgment. While Mann uses the
metaphor of living horizontally as a literary device, his analysis also contains insight that captures
an important facet of sanatorium life. See Mann, 270—300. Literary critic, James Wood, has also
discussed the importance of Mann's "horizontal" leitrnotif in regards to death. See James Wood
The Broken Estate: Essays on Literature and Belief (New York: Random House, 1999), 112—
113.

m I base this conclusion on the fact that the autobiographers in this study only wrote about their
fear of death when they were on bed rest and not later in their rehabilitation when they were given
ambulatory privileges and allowed to participate in occupational therapy. One obvious
explanation for this would be that death was not as much of a threat when patients were given
activity privileges, for in receiving these privileges, they were considered to be medically
progressing towards health. Another plausible explanation, which is tied to the theme of
teleology in chapter 3, is that with activity, patients were given a goal which occupied their
thoughts and distracted them from the possibility of death.

46

I felt close to the earth, closer than I wanted to be. It made me afraid, it made me think of
death.”127 MacDonald describes a similar feeling of fear of death when lying in bed at
night. Not being able to sleep at night because of too many rest hours during the day,
MacDonald writes “[I] had long sleepless hours to think, to listen, and to observe,
I...began to see [death’s] evil peering face, to hear him shuffling up and down the
corridors in the night.”128 Perhaps for MacDonald and Ross lying horizontally simulated
too closely the final position of death, evoking fears that they were heading for a final
resting place rather than the return to the lives they had left behind.

Aside from the mundaneness and anxieties of death which seemed to accompany
the horizontal life, the sanatorium patients also indicate that continuous confinement to a
bed eventually led them to experience space differently from when they were healthy.
Smith sums up the phenomenon of her changed perception of space best when she writes,
“the longer I was sick, the longer I lay in bed, the more the molehills began to appear as
mountains.”129 The thought of performing normal, everyday tasks, began to seem like
daunting undertakings. This became particularly apparent to patients once they were
taken off strict bed rest (usually after three months) and given ambulatory privileges.I30
The newly gained independence of being able to walk was received with much awe and
speculation. For instance, when Ross was allowed to eat his meals in the dining room, he

treated his new independence as if it were a very special occasion. Using the metaphor of

 

”7 Ross, 95.

"3 MacDonald, 160.

'2’ Smith, 61.

'30 MacDonald explains the rehabilitation timetable at her sanatorium, claiming that if patients
showed signs of physical recuperation after one month, they would be granted bathroom
privileges, and would be allowed 15 minutes of writing and reading. After 2 months, reading
time would be increased to 30 minutes. After 3 months, recuperating patients would be granted
ambulation privilege, which meant that they could walk to different areas within the confines of
the sanatorium. MacDonald, 142.

47

taking a voyage by ship, Ross describes his new freedom in terms of traveling great
distances when he writes, “I was delighted to be getting away from my mattress island
and launching off towards to the mainland [of the dining room]?13 I From the perspective
of a “horizontal,” who spent three to fours months on strict bed rest, a simple everyday
task like walking to the dining room became an exciting voyage, which required much
planning and brought about anticipation and anxiety. What would be a small, almost
insignificant, distance to a healthy person expanded exponentially for bedridden
sanatorium patients.

A transformation in the perception of space, such as Ross’, suggests that while it
is true that sanatorium patients were confined to a particular institution—to its rules, and
to a bed—such a description only explains how objectified, physical space had
constricted. But, when one looks beyond the objective facts of confinement to investigate
how this affected the patient's subjective awareness of space, one finds that for patients
like Smith and Ross, space often seemed to expand. They both felt as if the distance
between themselves (and their beds) and anything beyond their beds had increased.
Confined to a bed, to an objectively confined space, sanatorium patients naturally focused
on their immediate surroundings of the ceiling, the window, the bed, or the room. In fact,
during the initial months of a sanatorium stay, it was often the case that patients did not
even know what lay outside of their own doors.I32

Thus, the living space of a single room and perhaps the porch on which they were

taking the rest cure became the dominant context of the patients’ lives. Sanatorium

confinement to a bed relegated them to a context in which space took on a new meaning—

 

”‘ Ross, 113.
'32 Ross, 85.

48

—where molehills looked like mountains, and a trip to the dining room looked like a
voyage to a far—off, distant land. At times, such a change in the daily life of a horizontal
was accepted with great enthusiasm. But more often than not, such a change in
perceptual awareness was met with fear. For example, even though Ross was at first
enthusiastic about his ambulatory privileges, he latter writes of feeling of a greater
dependency, for he did not want to leave his bed. As he writes, “I was afraid to face the
outside world.”'33 Living life confined to a bed, the outside world must have truly
seemed like a great expanse.
In the Kingdom of the Sick

While prolonged bed rest often contributed to feelings of helplessness, heightened
fear of death, and altered perceptions of space, the most pronounced psychological effect
of confinement was that patients often felt a profound social isolation from the outside

world and their loved onesm

The geographical separateness and confinement of the
sanatorium eventually led many patients to feel cxperientially disconnected, sometimes to
the point of being unable to relate to the people or the events in the outside world. That
certain types of sickness promote one to feel alienated from healthy people is a

phenomenon that many scholars have discussed. But as J. H. van den Berg points out, a

patient’s alienation is most acute when he or she is confined to a bed, for the once

 

'33 R055, 122.

'3‘ I chose to entitle this section “Kingdom of the Sick,” for all of the autobiographies make as
distinction similar to Susan Sontag’s metaphorical kingdoms of the well and sick. See Susan
Sontag, Illness as Metaphor and Aids and its Metaphors (New York: Anchor Books, 1990), 3ff.
In the sanatorium narratives, patients write of a world “inside” the sanatorium walls which is very
different from the “outside world.” See, for example, Smith, 43 and R055, 116, 122.

49

inhabited world of the bedridden patient only “echoes as though from an inaccessible

distance?‘35

Indeed, the more time sanatorium patients stayed in bed, the greater their sense of
alienation became. For example, MacDonald explains that as her time in bed increased,
so too did her apathy toward her family and friends.

At first when visitors told me of happenings in the outside world I was vitally

interested and relived each incident vividly with the telling. Then gradually,

insidiously, like night mist rising from the swamps, my invalidism obscured the

real world from me and when my family told me tales of happenings at home, I

found them interesting but without strength, like talk about people long dead?"5
To MacDonald, the people who made up the outside world had become remote and thus
they inhabited only a place in her distant memories. Not being able to physically
associate with her family and friends in the context of her home or community,
MacDonald lacked the necessary experiential interactions which allow one to take an
interest in others and appreciate the meaning of those experiences. Moreover, because of
her confinement to bed and resultant sense of “invalidism,” the outside world no longer
seemed “real.” Relating to her family’s stories became difficult for MacDonald because
to her “the only real things were connected to the sanatorium. The only real people
[were] the other patients, the doctors, the nurses.”137 Under the sanatorium regime, a
mental wall was constructed, creating a clear divide between the healthy and the sick.

From her bed, MacDonald could no longer reach those for whom she cared, nor could

they reach her; confinement had undermined her ability to connect with her family and

 

'35 J. H. van den Berg, The Psychology of the Sickbed (Pittsburgh: Duquesne University Press,

1966), 26, quoted in Drew Leder, The Absent Body (Chicago: The University of Chicago Press,
1990), 81.

'36 MacDonald, 164—5.
'37 MacDonald, 165.

50

friends to such an extent that she had to struggle against a feeling of indifference towards
her prc—sanatorium life.

Other patients, like Smith, not only began to lose interest in their families, but
also in society as a whole. On the eve of World War 11, Smith writes about the difficulty
of relating to the political happenings of the outside world; “[the radio] spoke of a world
remote and far away. Only my bed, table, bureau, and two chairs seemed real. I had
little tangible proof that anything else existed.”I38 While both Smith and MacDonald
intellectually knew that the world outside of the sanatorium was real and that their
families, friends and society still existed, being confined to the sanatorium nevertheless
had the effect of making everything beyond the sanatorium walls so distant that it no
longer appeared to be physically or mentally concrete, making worldly events seem
unimportant.

One of the major contributing factors to this felt alienation on the part of the
patients was that many of them started to forget what made their former ways of life
meaningful. Thinking about her life experiences before she was admitted to the
sanatorium, Smith began to ponder the significance of some of the fundamental premises
under which the outside world operated.

I could remember distinctly...the appearance of a street, but I had forgotten the
way a sidewalk felt beneath my feet. I could remember the business of a morning
at home, but what had been the tasks which made those hours so full? I stared
sometimes in bewilderment at the automobiles hurrying back and forth on the
highway below my porch and tried to visualize the press of business and the rush

of everyday affairs that kept these people forever on the go—but I had little
success. '3

 

‘38 Smith, 168.
‘39 Smith, 104.

51

It is not surprising that Smith suffered a kind of kinesthetic forgetfirlness. After all, she
spent months confined to a bed, restricted entirely from ambulatory privileges. But her
forgetfulness did not simply stop with proprioceptive feelings. Rather, from her
completely passive state in bed, Smith could not remember the motives behind the
dynamism of the outside world. Although she was once part of the outside world as a
student nurse, Smith could no longer understand the raison d ’etre of the healthy, working
people whom she viewed from her sanatorium window.

As memories faded and the everyday happenings of the outside world started to
look foreign in comparison to the sanatorium, some patients found it difficult even to
communicate with their friends and families. For example, Smith writes, “I wanted
desperately to speak the same language as my friends...[but] we did not, for the most part,
even think the same thoughts.”140 The problem for Smith was that while her friends and
family concerned themselves with the business of the everyday world, she was primarily
absorbed with the events of the sanatorium. So whereas a healthy family member might
be concerned with a job promotion or raising a family, sanatorium patients were
preoccupied with body temperatures, weight gain and rest. Even when family members
and patients used a common vocabulary and ostensibly engaged in a discussion in which
both parties understood what the other was saying, the patients still felt as if their families
didn’t understand. As MacDonald writes, “I was certain that my family hadn’t the least

idea of the meaning of the words rest and quiet...?'“ So although family members may

 

"° Smith, 146.
'" MacDonald, 232.

52

have uttered the right words, patients like MacDonald felt that their loved ones did not
understand the full import of the meanings of words such as rest.142

Although the feeling of alienation was at times all—pervasive for the patients,
most of them did not treat it as an unavoidable fate. The autobiographers in this study
not only indicate that they were self—consciously aware of their felt isolation; but they
understood such feelings of alienation to be undesirable and thus looked for the cause of
such emotions, the removal of which would enable them to attain a healthier state of
mind. Most of them attributed the cause of their isolation to themselves—they felt that
they had allowed themselves to become so self absorbed by their own state of sickness
that they could not think of anyone else. Even a single mother like MacDonald had this
experience. Although she constantly worried about how she could support her two
children, MacDonald nevertheless was conscious of the fact that her interests in others
and the outside world were dwindling. She blamed her lack of interest in part on “the
childish self—centered attitude of an invalid. What I was doing, how I felt, what was to
happen to me became more and more important to me as time went on.”143 MacDonald
felt that the concern for her own welfare had absorbed the scope of her attention to such a
degree that she could no longer give adequate attention to those closest to her.144 And, in
her mind, she had only herself to blame for allowing such feelings of egocentrism to
dominate her life; MacDonald firmly believed that her egocentrism was a flaw in her

character that she could willfully overcome.

 

"2 In fact, it is likely that this type of communication gap persisted well beyond a patient's
discharge from the sanatorium, for as Bryder demonstrates, many patients continued a modified
sanatorium life at home even after they were discharged. See Bryder, 215ff.

"3 MacDonald, 164.

1“ Mary C. Rawlinson, “Medicine’s Discourse and the Practice of Medicine,” in The Humanity of
the III: Phenomenological Perspectives, ed. Victor Kestenbaum (Knoxville: The University of
Tennessee Press, 1982), 74— 77.

53

While some patients blamed themselves for their self—centered attitude, others,
like Smith, recognize that the real culprit was the rest cure and confinement to bed.
Smith seemed to fully appreciate the detrimental effects that confinement had on her
psyche. AS she writes, “I longed to lose myself in something so big that my own
[egocentric] concerns would become unimportant. But where and how was I to find it in a
twelve by twelve room?”I45 Because of her situation in the sanatorium, Smith found it
virtually impossible to think of anything else but herself. At one point she candidly
admits that the rest treatment was making her much worse, rather than better. From her
bed she writes, “I was stagnating in the swamp of my woes. The only thing that
flourished, and that most unhealthily, was my ego.”146 Someone like Smith indicates that
tuberculosis itself was not the only causative factor in feelings of solitude. Rather, it was
the treatment that was the main cause—lying in bed for weeks and months promoted

egocentrism and isolation that was almost impossible to overcome.

 

“5 Smith, 168.
"6 Smith, 56.

54

CHAPTER 3
THE POSSIBILITIES OF PROJECTION: SANATORIUM HORIZONS

In his book entitled The Absent Body, Drew Leder argues that because sickness
brings about physical pain and discomfort, an ill person’s concern for his or her own
body eclipses future plans and goals. In making this argument, Leder claims that when
sickness ensues, a person is no longer able to project goals onto the firture. That is, the
normally projecting self is disrupted insofar as the “rays of intentionality [which
normally] radiate outwar ” from a healthy person collapse during times of sickness. At
these times the body is no longer seen as a reliable vehicle through which one’s future
plans can be accomplished.147 Because future possibilities and life plans seem to be no
longer feasible, those who suffer from sickness, Leder argues, experience a “teleological
constriction?”48 .

In light of the tuberculosis narratives, Leder’s theory of teleological constriction
characterizes one important facet of the sanatorium experience. Indeed, the times in
which the autobiographers actually felt sick and suffered from physical symptoms of
tuberculosis, they write that their bodies were failing them and that their future plans
were outstripped by their feelings of Sickness. Yet, because the autobiographers had
incipient cases of tuberculosis, many were asymptomatic for most of their sanatorium
treatment. Given this fact, it would seem to follow that because they did not experience

any bodily symptoms of their disease, they would not suffer from a teleological

constriction.

 

"7 Leder, 80-81. Many of the ideas for this chapter were inspired also by the phenomenological
analysis found in Martin Heidegger, Being and Time, trans. John Macquarric and Edward
Robinson (New York: HarperCollins, 1962), 185ff., 97—109; and Maurice Merleau—Ponty,
Phenomenology of Perception, trans. Colin Smith (New York: Routledge, 1996), 1011f.

"8 Leder, 79-83.

55

But this was not the case. For although most sanatorium patients were not
burdened by symptoms which constantly put their future plans into doubt, they did have
to endure a treatment regime which, in essence, forced a kind of teleological constriction
upon them.

In the sanatorium narratives, there is a subtle yet crucial distinction to be made
between, on the one hand, a teleological constriction which may arise from patients
focusing on their physical ailments to such an extent that they can no longer even
conceive of future possibilities and, on the other, a constriction which occurs as the result
of external restraints (such as prolonged bed rest and restraining medical advice) which
preclude patients from acting toward goals they continued to hold. That is, although
many of the patients were asymptomatic and thus were able to still imagine and dream of
their futures, they nevertheless began to experience a kind of teleological constriction that
resulted from not being able to act toward their own plans since they were expected to
remain in bed for an extended period of time despite their subjective feelings. Thus, for
many of the patients in the sanatorium, the disruption of making life plans did not simply
arise as a result of the disease in itself. Rather the order of prolonged bed rest and other
medical restrictions on their lives had the effect of collapsing their sphere of future life
plans so that the only meaningful purpose left was to “take the cure?

The Patient’s Worldview

Since sanatoria in the second and third decades of the twentieth-century began
favoring admissions of incipient cases of tuberculosis, many patients who were admitted
during this time period had a general sense of physical well—being for a large majority of

their sanatorium stay. Nevertheless, they still had chronic illnesses and were thus prone

56

to occasional relapses that were marked by a wide—array of symptoms such as pleurisy,
increased body temperature, and lethargy. Often, the physical manifestations of their
disease brought about feelings of despair and grief. Symptoms of pain and discomfort
served as reminders of their fragile states—recuperation was by no means fully
guaranteed. Recounting a relapse of his own, Ross writes, “my temperature
persisted....my horizons were again limited to my mattress.”I49 Invoking the metaphor of
“limited horizons,” Ross is expressing feelings of teleological constriction. And, it was
the kind of constriction that, in accordance with Leder’s theory, was largely due to the
experience of bodily pain or suffering. Because his body was ostensibly failing him, any
thoughts that began with the conditional of “when I get out of the sanatorium” were
suddenly put into question, replaced, perhaps, by an image of a “slamming coffm lid?‘50
He had difficulty imagining any future plans, for his feelings of sickness forced him to
narrow his outlook and focus on the primary and necessary goal of overcoming his febrile
state.

Along with naturally occurring relapses, many sanatorium patients during the
twentieth—century suffered iatrogenic pain from extreme and often hazardous surgical
methods which were often employed as experimental means to combat the disease. In
the absence of effective drug therapies to combat the tubercle bacillus, procedures such as
artificial pneumothorax (the injection of gases into the lung cavity) and thoracoplasty (the
resection and removal of part of the rib cage) were very popular in the sanatoria of the
early to mid— twentieth—century.151 Both procedures were used to induce the affected

lung to collapse, a technique that was believed to hasten recovery. Although revered,

 

"9 R055, 119.
"° MacDonald, I89.
"' Scale and Pattison, 48—49.

57

these procedures were often quite painful. After undergoing her first pneumothorax,
Smith writes, “I lay bolstered high on my pillows...with every breath making me wince, I
knew that all my hopes for the future had collapsed along with my faithless lung.”152
While in pain, Smith indicates an acute bodily awareness that essentially made her firturc
uncertain. As her hopes collapsed, so too did her teleological sphere. Like Ross in his
relapsed state, Smith’s goal of becoming pain—free overshadowed any of her other future
goals.

But outside of the times that they were recovering from surgery or recuperating
from a relapse, the autobiographers in this study indicate they were often symptom—free.
In fact, many patients shared the same sentiment as Smith, who claimed that after a week
or so of bed rest, she “felt well and more rested than [she] had in years.”153 Similarly,
after the first two weeks of the rest cure, MacDonald writes:

My sense of well—being was so great it was almost choking me. . . .The depression

and tenible sense of foreboding I had been wearing around my shoulders since

the night I learned I had tuberculosis, had been lifted. ...I felt welll'54
Considering the fact that prior to their admissions, many sanatorium patients were
working full—time jobs and taking care of a families while combating symptoms of
coughing, pleurisy, and low—grade fevers, it is not at all surprising that, in comparison to
their pre—sanatorium life, many of the patients felt healthier after a couple weeks of the
rest cure.

For most of their sanatorium stay, many patients felt perfectly capable of carrying
out simple daily activities, for they had a teleological drive similar to that of a healthy

person. Making future plans and goals seemed perfectly normal and appropriate, for

 

“2 Smith, 50—51.
"3 Smith, 46—47.
‘5‘ MacDonald, 107.

58

having a sense of physical well—being, their bodies were not indicating that they should
think otherwise. Patients like Smith and Seagrave, who both had fiancés upon their
diagnosis of tuberculosis, continued with wedding plans during the initial months of their
sanatorium stay. As Smith recounts, “Ted [her fiance] and I planned endlessly for the
future. ...”m Likewise, Seagrave, who maintained a correspondence with her fiance,
Darwin, wrote him a letter saying “there can be no comparison between this [sanatorium
living] and entering upon my life with you this fall, as [we] are planning. There should
be no question of the feasibility of these plans. ...”l56

If wedding plans were not in the making, other goals like returning to their
careers, homes and families occupied the patients’ minds. McClintock recounts how
when his wife Helene recuperated from her pleurisy pains, she said, “I’m beginning to
want so many things. . ..I lie here all day and think about having a house and good
furniture and. . .a car. . ..”'57 MacDonald also continued to have thoughts about returning
home, but her concerns mainly revolved around her two children. Well—rested and
feeling healthy, she writes, “I spent the rest hours making plans for the future. ...I was
able to think of home and the children without the slamming ofa coffin lid.”'58 Still
other patients had plans to return to their professional careers once they had firlly
recuperated. Smith claims that, during the initial month of her sanatorium stay, she
“never ceased to ask: When can I finish training?” For despite her setback of

tuberculosis, she fully intended to continue pursuing her career as a nurse.

 

'5’ Smith, 52.

"6 Seagrave, 171.
"7 McClintock, 128.
"8 MacDonald, 109.

59

While for many patients the ability to plan for the future still thrived, what
ultimately mattered in the sanatorium was medical fact—facts that did not necessarily
coincide with subjective feelings. In the early decades of the twentieth-century, with the
increased influence and acceptance of germ theory and laboratory medicine, the
incongruity between fizeling well (subjective perception), and being sick (empirical fact)
was something to which many of the sanatorium patients had to become accustomed. In
her recent book Typhoid Mary, Judith Leavitt claims that during the turn of the
twentieth—century, there was a rift between the “official” or professional worldview
which understood sickness and disease in terms of germ theory and the patient worldview
which relied more humoral notions of symptomatology. The worldview of laboratory—
minded physicians and public health officials was one dominated by laboratory sciences
and notions of “healthy carriers.” But to the patients who had contagious diseases, like
Mary Mallon, the notion of a “healthy carrier” was far from obvious, for they did share
the same knowledge base as their treating physicians. Instead, as Leavitt points out,
Mallon relied on “her experience as a healthy woman above a science that defined her as
infected?”59 Without a microscope or access tothe esoteric knowledge of the new
laboratory sciences, many patients relied on what they knew best: how they physically
felt.

In the sanatorium narratives of the early twentieth-century, there is a clear
indication that patients had some difficulties accepting the new medical evidence that
deemed them sick. Exhibiting a worldview similar to Mallon’s, Smith writes, “I didn’t

know how sick one can actually be even though feeling better.”160 Smith explains that

 

"9 Leavitt, 35, emphasis added.
'°° Smith, 24.

60

she had difficulty believing the seriousness of her disease because it was not made
apparent to her. Her subjective feelings were that of being healthy—she had no other
empirical evidence which indicated otherwise. Smith writes about the difficulty in
coming to terms with the disparity between her subjective feelings and the empirical
findings of the medical sciences:

I was presumably patching a pair of damaged lungs. But I could not SEE my

lungs. And the few glimpses I ever had...[of] my X—ray pictures revealed nothing

I could understand....Without seeing, believing was difficult.161
Smith’s emphasis on seeing actually highlights a fundamental change that took place
within the medical field as it shifted from the pre—modern humoralism to the clinical and
laboratory sciences of late nineteenth—century. Under the medical paradigm of
humoralism, both patient and doctor would rely on outward symptoms for diagnosis and
treatment, whereas the laboratory sciences increasingly based medical knowledge on
microscopic findings.

Michel Foucault in his The Birth of the Clinic describes this shift in the history of
medicine as a reorganization of the “medical gaze?”62 While humoral physicians relied
mostly on outwardly exhibited symptoms, modern clinical and laboratory medicine
adopted a new gaze which “was not content to observe what was self—evident...”163
Instead, it was a gaze that penetrated beyond that which was immediately apparent.
Through the use of microscopes and X—rays, physicians employed a new kind of
perception that went beyond the individual patient. But what became visible to medicine

remained largely invisible to the patient.

 

'6' Smith, 55, emphasis in original.
'62 Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, trans. A. M.
Sheridan Smith (New York: Vintage Books, 1994), 89 ff.
"3 Foucault, 89.

61

Although certain patients had some personal misgivings about the new laboratory
sciences, they rarely, if ever, acted on their skeptical inclinations. Throughout the
sanatorium autobiographies, one finds that, for the most part, patients readily complied
with medical advice. Most patients thought of physicians as the “experts” concerning
health and disease, for they possessed a high degree of skill and thus knew what was best
for the welfare of the patient and community. On the other hand, patients were expected
to assume the sick role. And if they wanted to get well, they had to cooperate with
medical advice and be willing to refrain from normal activities and responsibilities.
Ultimately, for this type of medical relationship to work, both parties had to understand
that the patient was the passive recipient of care and was “unable to get better by his or
her own decisions and will?“54

But even though patients frequently acquiesced to the doctor’s orders, the
discrepancy between feeling well and being sick still took its toll on a more personal and
psychological level. Because medical fact ultimately held more weight than subjective
feelings in treatment protocol, patients were restricted to prolonged bed rest despite their
feelings of well—being. As a result, patients not only had to contend with an unrelenting
feeling of restlessness, but they were also forced to narrow their horizon of possibilities
to the singular goal of being discharged from the sanatorium.

Restlessness

Often having to take it on blind faith that they were sick, sanatorium patients had

a difficult time tolerating the passive existence of confinement and the rest cure, for they

felt well and thus maintained a mind-set of planning and doing. Despite the good

 

1“ Much of this discussion is based on Talcott Parsons’ theory about patient and doctor roles
found in Scale and Pattison,] 1 l.

62

intentions of the medical community to keep tuberculosis patients completely passive and
removed from the worries of everyday life, nothing could stop many of the patients from
planning and thinking about future endeavors. “Even here, in this Adirondack village,”
Smith writes, “[my life] continued to have color and possibilities which did not produce
the mental attitude prescribed for a resting patient.”165 In fact, Smith claims that having
even simple daily goals was necessary for her will to live. She writes:

Each morning I awakened with the same thought. I must find something,

somehow, to which I could immediately look forward. This daily search was well

worth the effort, for, once found the anticipated pleasure would serve to enliven

my spirits and give zest and meaning to the hours ahead....and anticipation to me
was life. '66

Although in the early days of her sanatorium stay Smith believed that anticipation was
enough to satisfy the prerequisites of living, she, along with many other patients, would
later come to realize that simply dreaming of goals without being able to act towards
them was not enough to satisfy the desires of a normally projecting self.

The sanatorium life of prolonged bed rest was a unique challenge to the patients’
teleological drive, for although they could still mentally conceive of future plans, they
were prohibited from acting towards any of those goals. As a result of such restriction,
patients suffered a kind of teleological constriction which manifested itself in symptoms
of persistent restlessness. After her initials days in the sanatorium observing her
roommates, Seagrave writes, “Perhaps I’ll feel more unruly when I feel better
physically,” knowing full well that the imposed rest cure would be difficult for her to
carry out once her symptoms of fatigue and listlessness subsided. '67 Seagrave’s portent

was very insightful, for every autobiographer complained of restlessness only after he or

 

"5 Smith, 39.
'6‘ Smith, 47.
“’7 Seagrave, 56.

63

she began to feel well. “My...scnse of well—being returned but...it was accompanied by a
terrible restlessness and irritability,” MacDonald writes after undergoing two weeks of
the rest cure. She continues, “I felt perfectly well and it drove me insane to lie there hour
after hour, day after day, doing nothing?“58 Restlessness was primarily a symptom of
those who felt well because it was born out of a fundamental discontinuity of the
normally projecting self—of having beautiful and exciting plans in the mind’s eye but
being inhibited from setting forth to accomplish them.

In some cases, confinement to bed only served to further intensify the patient’s
desire to conceive of filture plans. Only a few weeks after her arrival to the sanatorium,
Smith, in a state of fi'ustration, contrasts her active mind with her passive body, “Lying
still became a difficult task in which my mind refused to co—operate. My thoughts
charged ahead with a speed that almost compelled action. Sleep eluded me as I endlessly
planned for the future, not just tomorrow, but next week, next year....”169 The tone here
suggests that Smith was becoming compulsive about the future just by the very fact that
her teleological desires were not being met. Simply thinking of the future was not
enough for her; she wanted to act toward it.

For most patients, planning for the future was often extremely dissatisfying,
primarily because it was futile, for they were under the strict medial advice not to do
anything, even the most menial tasks. In fact, it was virtually impossible to contrive any
goals that conformed to sanatorium rules. As Smith laments, “The inability to do
anything for myself except dab my nose with Kleenex began to get on my nerves.” She

claims that she repeatedly asked the medical staff to allow her to do more for herself.

 

'68 MacDonald, 113.
"9 Smith, 47.

64

She writes, “ I begged to hold the washcloth in my own hands, to scrub my own teeth and
comb my own hair.”170 Performing even the simple everyday tasks, life personal
hygiene, was important to Smith, for she intuited that the teleological constriction that
was being forced upon her through prolonged bed rest was detrimental to her
psychological health.

Patients in the sanatorium were thus put in the difficult position of trying to come
to terms with two opposing desires. One the one hand, many could not help but to dream
of the future and, in fact, many believed that such a mind—set would benefit their mental
well—being. But, on the other hand, such mental activity (they were told) was detrimental
to their physical health, putting their chances for a cure in jeopardy.

The struggle, then, for the sanatorium patients who wanted to remain in good
standing with their physicians was that as they progressively. felt better, they had to
remind themselves that (according to their sputum and X—rays) they were sick. This was
a difficult undertaking, for as the physical symptoms of their disease wore off, not only
did patients feel better, but they also experienced a kind of psychological solace since
their disease state was less threatening. “As my fever subsided,” Smith recounts, “the
spot on my lung did not seem so menacing. ...”m But in order to continue to pursue
their hopes of being cured, patients had to subvert their subjective feelings to scientific
facts. Smith describes such a task as a daily battle when she writes, “I had to remind
myself continually that my lungs were sick, because the remainder of my body actually
seemed overcharged with energy?”2 MacDonald recounts a similar struggle and

conveys what must have been a trying situation for medical professionals as well. “[The

 

“’° Smith, 23.
‘7‘ Smith, 23.
"2 Smith, 46-47.

65

medical director] had had a most difficult time teaching me that I had tuberculosis,”
MacDonald explains, “he still wasn’t sure that I realized how serious my illness had
been.”'73 This discussion between MacDonald and her medical director took place on
many occasions throughout her four-month stay. In fact, even upon her date of
discharge, MacDonald’s doctor gave her the following words of advice: “the important
thing...to remember is...that you had a cavity in your left lung and a shadow in your right
lung. You have had a serious tuberculosis, do not forget it.”174 Even until the end, it still
took a great deal of conscious effort on MacDonald’s part to remember her
microscopically fragile state.

Narrowing the Horizon

Despite the detrimental side—effects of prolonged bed rest, some patients persisted
in making life plans. But, as soon as these patients shared their future plans with their
treating physicians, most of their goals were deemed medically unsound. Trustng the
advice of their physicians, most sanatorium patients eventually gave up their broad range
of life—plans and replaced them with the solitary and “medically acceptable” goal of
taking the cure in the hopes of discharge.

Some of the most basic future goals and plans that many patients held prior to
their admission to the sanatorium were not viable options according to their physicians.
For instance, women in the sanatorium were often discouraged from making plans of
marriage and having children. Indeed, the advice given to Seagrave by her treating
physician was to avoid taking any such chances, for “lungs do not heal permanently for a

long time, and marriage with its adjustments to a new environment, and the probability of

 

”3 MacDonald, 239—240.
”‘ MacDonald, 239-240.

66

childbirth, might be factors which would soon undo all...improvement...?175 Patients in
the sanatorium were essentially beng told that they must adopt a sedentary life not only
for the duration of their sanatorium stay, but for life. Physicians had begun to believe in
the benefits of rest to such a degree that activity, even after the patient was discharged,
was thought to be a risk too large to take. Had Seagrave lived prior to Koch’s discovery
of the tubercular bacilli, in all likelihood she would have never received such advice. In
fact, according to Sheila Rothman, physicians of the nineteenth—century would have
never advised a woman to refiain from having children, for they assumed that she would
never accept such advice.'76 As Rothman points out, the sentiment of the time was that
“bearing children was a woman’s duty, and medicine had no business in abrogating it.”177
But with the rise of laboratory medicine, and the view that medical professionals were the
experts in the matters of health and disease, physicians took greater license in controlling
patients’ lives, and, for the most part, patients accepted it.

For the men and women who held jobs prior to entering the sanatorium, their
career paths were often abruptly cut off upon admission. Indeed, this fact often caused
great concern and worry, especially for those who had a family and children to support.178
But besides the obvious economic worries of making ends meet, cutting off one’s career
essentially meant radically disrupting a patient’s life plan, the pursuit of which largely

shapes one’s identity.'79 For instance, Smith was left floundering and aimless for a great

 

”5 Seagrave, 177.

'7‘ Rothman, 107.

"7 Rothman, 107.

"8 Bryder, 211ff.

"9 Heidegger, Being and Time, 185-186. This idea that one’s personal identity is shaped both by
one’s past as well as one’s projected future echoes in a wide array of literature today. Those
involved in literary circles certainly have a great appreciation of viewing human life as a
narrative. Common to this idea of narrative is that our life stories usually begin within a given

67

deal of her stay after her doctor advised her that “[she] must give up all thoughts of
becoming a nurse?”80 Unfortunately, in the sanatorium, Smith did not have a plethora of
options to replace her goal of being a nurse.

Advising someone to make a career change due to an illness was not something
unique to the medical practice of the early twentieth-century. Like their tuberculosis
counterparts, consumptives of the nineteenth century were also dissuaded from pursuing
certain careers. As Rothman points out, men who had the propensity to pursue a career in
academics were highly discouraged from doing so because a bookish, intellectual career
was considered to be detrimental lifestyle, especially for someone who had the fate of a
poor constitutional endowment working against him. Physicians of the nineteenth—
century thus encouraged many consumptive patients (for the most part, only men) to
pursue a more active lifestyle, of farming or sea—voyaging.181 It is out of this nineteenth—
century humoral thinking about consumption that we see consumptives, known as
“health-seekers,” who traveled to the dryer climes of Western America, adopting the
lifestyle of rugged frontiersmen.

But the demands made on the sanatorium patients were far more extreme. For
while consumptives were advised to give up their dreams of certain careers, they, unlike

their twentieth—century counterparts, were nevertheless encouraged to remain active. As

 

family and in a given socio-cultural context, elements which are beyond our own choosing or
awareness. See, for instance, Howard Brody, Stories of Sickness (New Haven: Yale University
Press, 1987), 44. Heidegger calls this phenomenon “thrownness.” It is this background or
“introduction” to our life stories which greatly shapes our ranges of possibilities throughout the
rest of our narrative lives. But, as with any story, our lives are constantly in a state of unfolding,
and thus the field of possibilities are always changing. As if they were ballroom dancers, the past
and future are closely connected but with the future always taking the lead. In a sense, then, as
human beings, we are positioned at the axis around which the past is constantly being
reinterpreted in light of the future possibilities.

"‘° Smith, 24.

'8' Rothman, 29—45.

68

“health—seekers,” they were encouraged to undertake a new lifestyle by their own
volition—a lifestyle which mimicked that of the most healthy and robust persons. They
were not told to stop making plans; rather they were advised to change course, to alter the
trajectory of their projections. Sanatorium patients, in contrast, were told to put all of
their plans on hold and primarily to live by the golden rule of rest. To be sure,
tuberculars and consumptives shared the overarching goal of becoming well again, but
those in the sanatorium had to take it lying down. Moreover, while the consumptives
could define themselves as sea voyagers, farmers, mothers, or health—seekers, their
tuberculosis counterparts Simply had to define themselves as patients.

Thus for many of sanatorium patients it was not necessarily the feelings of
sickness to which they had to become accustomed, but rather it was the totally new
context and environment in which they were supposed to live their lives. Discouraged
from taking on the normal daily responsibilities of maintaining a household or holding a
job, they had little other choice but to narrow their horizons to the goal of taking the cure

so well that they could enjoy a speedy recovery and discharge.

69

CHAPTER 4
THE TEDIUM OF TB: SAN ITORIUM TIME

Many contemporary historians of tuberculosis and the sanatorium movement in
the United States and Great Britain find little of historical use in Thomas Mann’s The
Magic Mountain. Bryder explicitly sets herself apart from Mann by entitling her book
Below The Magic Mountain, wording which is used to highlight the fact that her story is
about “ordinary sufferers” rather than the wealthy elite who took their cure in the
luxurious sanatoria of the Swiss Alps. '82 The problem with Mann’s novel, according to
Bryder, is that, as a book which has largely Shaped the popular understanding of life in
the sanatorium, it is has perpetuated the false notion that tuberculosis was a disease of
romance. In Bryder’s mind, there was nothing positive about having tuberculosis,
especially at a time of wide—spread stigmatization and mandatory confinement. In a
similar vein, Rothman points out that, in most ways, the American sanatorium experience
was fundamentally different than the account given by Mann, for in The Magic Mountain
“fact mingles with fiction in a way that...obscures reality.” Like Bryder, Rothman also
takes issue with Mann’s title, arguing that in respect to the American experience, it is an
“utter incongruity [to] invok[e] a term like magic, when profound unhappiness,
disappointment, and despair were the dominant emotions [of the sanatorium]?183

To be sure, the American sanatorium experience of the twentieth—century belies
most romantic notions of tuberculosis—what most patients lived through was anything
but exotic, uplifting or exciting. Moreover, the relevance of Mann’s novel to the
American experience is surely questionable given the fact that Mann’s Davos sanatorium

was situated in the Swiss Alps, catered to the affluent, and closely followed the

 

"2 Bryder, 200.
"‘3 Rothman, 226—227.

70

Brehmerian rather than the Trudeaun philosophy of treatment. But despite these
differences, there is one very important aspect of the sanatorium experience that Mann’s
novel and the American autobiographies share: the patients’ constant concern with time.
It is in this respect that Mann’s description of the strange character of temporality in the
sanatorium is not merely fictional and not just a thought experiment, for the
autobiographies of the American sanatoria indicate that Mann had touched upon a very
real phenomenon.

Like Mann’s protagonist Hans Castorp, patients in the American sanatoria felt so
isolated from the outside world that the normal, objective indicators of time, such as
calendars and clocks, no longer held much meaning. Inside the sanatorium walls, days
became dominated by the patients’ subjective sense of time. Moreover, because of the
regime of prolonged bed rest and its effect of constricting their future possibilities to
becoming well, patients became obsessed with time, for it was seen as an obstacle which
stood in the way of attaining their primary goal. Since most patients did not have a
precise sense of how long they would have to remain in their beds before they would be
discharged, they had to adopt a kind of holding pattern rather than strive toward the
future. Or, as Mann describes it, they had to live in an “inelastic present,” a life in which
it was virtually impossible to measure any temporal progress being made toward the goal
of becoming well again.

The Relativity of Time
A fictional account of sanatorium life, Mann’s The Magic Mountain is largely a

novel about time. "’4 Voicing the novelist’s own opinion, the narrator explains that “there

 

m Sec Wood for a more thorough discussion about how, in Mann’s novel, time takes on many
different levels of meaning. See Wood, 103—115. For example, the most famous chapter of The

71

are situations in life on earth, or circumstance of landscape, in which confusion and
obliteration of temporal and spatial distances... is more or less natural and
legitimate...”185 For Mann, who had personal experience of visiting his tubercular wife,
Katia, in the Davos Waldsanatorium, the sanatorium is most certainly one of these
“landscapes,” for it is a place where time takes on a wholly different character compared
to the outside everyday world. '86 In fact, it is in this spirit that he titled his book The
Magic Mountain (translated from the German Der Zauberberg), which, among many
English—Speaking academics, has often been taken to mean a place of magical
enchantment—a fairyland where the residents take up a life a leisure. But looking at
Mann’s discussion of time, we find a much darker side to the meaning of “magic.” For,
in regards to time perception, Mann portrays the sanatorium as a soporific place where a
“magical” spell is cast over one’s sense of time, so that, in the end, objective measures of
time outside the sanatorium are essentially nullified.

The autobiographies of the American sanatorium patients indicate that once they
were admitted, they quickly lost touch with outside time. One can only imagine what it
must have been like to leave the daily routine of the modern, industrialized society—
where time is objectively measured to the minute by a clock, and one’s life is marked by

an almost constant activity of working and taking care of one’s family—to enter a place

 

Magic Mountain entitled “Snow,” presents a provocative metaphor for circular time and death.
For more about Mann’s presentation of time in the chapter “Snow,” sec Nancy P. Nenno,
“Projections on Blank Space: Landscape, Nationality, and Identity in Thomas Mann’s Der
Zauberberg,” The German Quarterly 69, no. 3 (1996): 305—321. For the purposes of this
chapter, however, I will be interpreting Mann’s conception of time only as it relates to the
mtients subjective perceptions vis-a-vis their sanatorium lives.

Mann, 536.
'86 In his biography of Thomas Mann, Donald Prater claims that Mann originally conceived of
The Magic Mountain in 1912 when his tubercular wife, Katia, took up temporary residence at the
Davos sanatorium in the Swiss Alps. See Donald Prater, Thomas Mann: A Life (Oxford: Oxford
University Press, 1995), 89—92.

72

where one was supposed to assume a reclined position for a large majority of the day. At
first, the switch in pace was disorienting. Trying to come to terms with her new routine
using the measures of the outside world, MacDonald describes her first rest period in bed
as a struggle in which she had to come to terms with sanatorium time. With a tone of
exhaustion MacDonald writes, “I looked at my watch. One o’clock: an hour and a half to
go [until it is over]?187 For the remainder of the ninety minute rest period, MacDonald
continuously looked at her watch, impatiently awaiting the end. Despite what her watch
told her, MacDonald sensed that time was going much slower than she thought it should.
Irritated with its slow pace, she asked herself, “how long was two hours anyway?”188

The passage of time, which she apparently had not contemplated much in her pre—
sanatorium life, suddenly came into question.

For many patients, losing touch with the hourly passage of time eventually
translated into losing track of the days. With one day seeming like every other,
McClintock admits that “the date, the days of the week, were never certain in my
mind.”189 True to the accounts of other patients, McClintock claims that with this
muddied, confused perception of time, “the days flew by with an amazing rapidity.”I90
For some patients, the only thing that would distinguish one day from another would be
the various weekly medical procedures. MacDonald claims that, “the days were all so
exactly alike and followed each other with such monotonous regularity that....I knew

them only as ‘gas’ day, bath day, fluoroscope day, visiting day, supply day or store

 

"7 MacDonald, 74.
"’8 MacDonald, 76.
"’9 McClintock, 109.
‘°° McClintock, 109.

73

day.”'9' While MacDonald intellectually knew that there was a measured time of the
outside world passing by, she was so “divorced from normal living” that it was difficult
for her to consistently care about such measures.192

Once they had become immersed in the sanatorium routine, many patients felt
that common indicators of time, such as clocks or calendrical days of the week, had no
usefulness and meaning. Describing what is was like to live in the sanatorium in a letter
to a friend, Seagrave writes, “talk about a well—regulated life! A...Swiss watch can’t
even begin to compete with us.”'93 In an almost surreal way, patients like Seagrave
began to feel as if they were more regulated than the measurements of time itself.
Understandably, they began to trust and rely on the sanatorium routine more than any
other indicators of time. Voicing an opinion similar to Seagrave’s, Smith writes, “I
began to really live the routine which eventually told the time for me so accurately that
for years I never had the need of a clock.”194 Patients felt that they had little need for
clocks or calendars because their daily lives were completely determined by the medical
professionals who had complete control over the sanatorium schedule.

Because outside measures held little weight inside the sanatorium walls, within
the same autobiography, it is often the case that a patient’s perception of the cadence of
time toggles back and forth between quickness and slowness. For example, although

MacDonald found her first rest periods to be a drudgery, she documents that, on the

whole, her first two weeks at the sanatorium were a period when time “went whizzing by.

 

'9' MacDonald, 164. For more on patients measuring the days by medical procedures, see Smith,
1 66.

'92 MacDonald, 164.

'93 Seagrave, 60.
'9‘ Smith, 30.

74

Everything was new, everything was interesting...”95 Here MacDonald attributes her
experience of time moving quickly to the novelty of her situation—she had a new routine
to learn, new people to meet and a new role to assume. Similar sentiments correlating
novelty with swiftness of time can be found in Mann’s novel. Likening the initial
sanatorium stay to a trip, the narrator claims that “the first few days in a new place have
a youthful swing to them, a kind of sturdy, long stride.” ’96 That is, with any change of
scenery, even if it is in a sanatorium, one’s sense of time takes on a youthful vigor, a
rebirth, if you will, making time “fly by.”

But such a sensation rarely lasts, especially in the sanatorium. Indeed, in stark
contrast to her sentiments about her initial two weeks as a patient in the sanatorium, as a
seasoned patients of two months, MacDonald writes, “I knew the routine. . ..This made
the time move with glacial slowness, made me even more restless and crotchety. Things
which I had grown to accept as part of being institutionalized suddenly became
unbearable....”'97 With every day being predictable, time became almost oppressive. In
the sanatorium, there was little opportunity for a rebirth of one’s sense of time once the
initial novelty of the sanatorium life wore off. Because of the regularity of sanatorium
operations, there was little if any noticeable change from one day to another. Prolonged
bed rest and the sanatorium habits and routines had a deadening effect on the patients’
sense of time; days became dull and monotonous, and time began to drag.

However, while some patients found that the boredom of the sanatorium routine
made time seem to drag, other patients suggest that the routine had the opposite effect.

For instance, Smith writes, “paradoxically enough this routine, whose sameness I had

 

'95 MacDonald, 107.
'°° Mann, 102—103.
'97 MacDonald, 168.

75

found so infinitely wearisome, ended by making the days pass with amazing
swiftness.”I98 Although Smith admits that the routine may have been boring on a day—
to—day basis, on the whole, the monotony had the effect of swallowing up the passage to
time. In fact, Ross speculated that the routine was instituted by the medical professionals
precisely for the purpose of making the “days move swiftly.”199
In the end, the effect that the context of the sanatorium had on temporal
perception reveals the powerful relatedness between space and time—not in an objective,
empirical sense, but as that which is experienced by a perceiving subject. The confining
physical space of the sanatorium, with its regulations and rules restricting freedom, led
patients to experience time as if it, too, were constricted, in meaning, in usefulness, and in
passage. Describing the intersection of time and space as it relates to the sanatorium, the
narrator of Mann’s novel writes that “time drowns in the unmeasured monotony of
space.”200 Sanatorium space had a way of making time something very alterable. In such
a place, it was possible to lose measurable time to such an extent that there seemed to be

nothing “actual” about time.201

Or as Castorp explained to his cousin Joachim,
sanatorium time was so yielding that it could pass “quickly and slowly, just as you
like.”202 Patients in the sanatorium were so cut—off from the outside world, that for them,

time was something wholly relative to their own perceptions.

 

‘98 Smith, 46.
'99 Ross, 90.
20° Mann, 537.
’°‘ Mann, 93.
”2 Mann, 14.

76

The Obstacle of Time

Although time was relative for sanatorium patients, for the most of their stay it
was perceived to pass slowly. For, having to remain in bed completely inactive, they had
no means by which to make time seem to pass more quickly through engaging in
activities. The patients themselves were aware of this fact and they hungered for any
degree of activity which would allow them to forget time. As MacDonald writes, “any
change was welcome,” for any alteration in the bed rest routine had the effect of making
time go by more quickly?” Likewise Smith writes, “the basic pattern of my days had
become so set that when my bed...collapsed one afternoon and catapulted me onto the
floor, I was delighted. Anything for a change.”204 Even the most banal events lessened
the tedium of tuberculosis.

Since sanatorium patients were precluded from taking on any activities, they were
essentially in a perpetual state of waiting—waiting for a change, waiting to be given a
clean bill of health, and ultimately, waiting to be discharged to return to their former
lives. And, as is indicated in The Magic Mountain, waiting in the sanatorium “mean[t]
seeing time and the present not as a gift, but as a barrier....”205 Thus many patients
became fixated on time, for it was that which not only precluded them from attaining
their goals, but which also made their sanatorium stay virtually unlivable. For example,
Smith writes, “I could not bear these days that were merely ‘time to kill.”’206 For Smith,

when time went slow, it was the enemy, something which she needed to ward off. She

 

203 MacDonald, 130.

204 Smith, 92, emphasis in original. See also MacDonald, 155.
’°’ Mann, 236.
’°° Smith, 56.

77

wanted to abolish time, to make time pass more quickly than her sanatorium lifestyle
would permit. 207

Ultimately the patients’ constant state of waiting contributed to the their feelings
of psychological unease, restlessness, and anxiety. Or as Heidegger once described it in a
lecture on the phenomenological experience of boredom, “passing the time has a peculiar
character of a fluttering unease that brings...impaticnce with it. For what happens in
becoming bored is that our unease...does not allow us to find anything that could grip us,
satisfy us or let us be patient.” 208 Having little—to—no control over their circumstances,
sanatorium patients could rarely find anything which would help them pass the time.
Indeed, if “passing the time is a way of taking action against the dragging of time that
oppresses us,” then sanatorium patients were left with little means to combat the
oppressor. 209

The “Inelastic Present”

The key to understanding the cadence of sanatorium time, then, is to appreciate
the fact that, in living every day in the same bed without any change, patients did not
have any clear indicators of making temporal progress toward their primary goal of
becoming well. Mann gives a very clear description of what such an experience must
have been like through his character Castorp, who upon a relapse, underwent several

weeks of complete bed rest.

It is always the same day—it just keeps repeating itself. Although since it is

always the same day, it is surely not correct to speak of “repetition.” One should
speak of monotony, of an abiding now, of etcrnalness. Someone brings you your
midday soup, the same soup they brought you yesterday and will bring you again

 

207 Martin Heidegger, The Fundamental Concepts of Metaphysics: World, F initude, Solitude
trans. William McNeill and Nicholas Walker (Indianapolis: Indiana University Press, 1995), 93.
208 Heidegger, The Fundamental Concepts of Metaphysics: World, F initude, Solitude, 94.

209 Heidegger, The Fundamental Concepts of Metaphysics: World, F initude, Solitude, 99.

78

tomorrow....The tenses of the verbs become confused, they blend and what is now
revealed to you as the true tense of all existence is the “inelastic present,” the
tense in which they bring you soup for all eternity.210
Because Castorp had no indicators of time, he became stuck in constant State of the
present, where even the basic premise of temporal progression could no longer be taken
for granted. The homogeneity of his bed rest days made every day seem so much alike
that it was difficult for him to “separate the ‘now’ of today from that of yesterday, or the
day before yesterday, or the day before that.” With the days blurring together, Mann
claims that Castorp’s sense of a present “now was apt, even likely, to muddle its present
with a present that had prevailed a month or a year before, and fuse into an ‘always.”’2"
Powerful echoes of this idea of the “inelastic present” can be detected in the
American sanatorium narratives. Patients consistently write of the monotony of their
days. For instance, after two months, MacDonald writes, “I knew the entire Bedrcst
Hospital routine by heart and could tell exactly what was going to happen every minute
of every day,” leaving her with little to distinguish one day fi'om the next.2'2 Even what
would seem to be a fundamental change according to sanatorium standards did not effect
the patients’ pervasive sense of monotony. Having been switched to a new room in the
sanatorium, with dashed hopes of finding a renewed sense of time in a new environment,
Ross languorously writes:
The change of [rooms] meant no particular change in my daily routine. I kept
right on with the usual formula: the waking up on schedule; the meals at their
appointed hours; the long rest periods faithfirlly observed; the comings and goings
of the doctor and the nurses; the daily questioning of the doctor and his

unsatisfactory answers; day after day, week after week, month following month,
the seasons changing but no break in the rigid discipline.213

 

2” Mann, 180.

2" Mann, 536.

212 MacDonald, 168.
2‘3 Ross, 101.

79

The tone of Ross’ account indicates that he was experiencing a similar sense of drudgery
and monotony that Castorp does in Mann’s novel. In fact, Ross’ experience of time was
not even effected by the obvious progress of time that he saw outside his window. He
was caught in the web of the “inelastic present” to such an extent that of was the change
of seasons did not matter, for his days inside the sanatorium walls were the same
regardless of seasonal changes.

In comparison to the outside world, it was as if time in the sanatorium had
stopped. And outside indicators of a change in time had little effect on sanatorium
patients. For instance, MacDonald claimed that she could estimate the admission year for
every patient just by his or her dress. She writes, “The degree of out—of—datedness [in
dress and hair style] varied with the length of time the patient had been at the Pines and
what had been in vogue when she entered.”214 Once patients were admitted into the
sanatorium, it was as if they stepped into a temporal vacuum.

What was ultimately at stake, though, in living a life of prolonged bed rest and
experiencing a perpetual “inelastic present,” was that there was no way for patients to
measure progress being made toward their goal of getting well. After seven consecutive
weeks of bed rest, Smith writes, “the weeks rolled by,” until she finally asked her doctor:
“Hadn’t I been in bed long enough?” To that her doctor simply replied, “You must rest a
long, long time.” With such a prognosis, Smith had no clear way of measuring her
progress toward her one goal of becoming well again. Not only was she unsure about

what constituted wellness fiom her physician’s perspective, but she was given no

 

2" MacDonald, 154.

80

milestones to look for along the way. Instead, she was simply left wondering how long a
“long, long time" could be.215

That medical professionals did not candidly discuss timetables or prognosis of
recovery with the patient was common within most sanatoria. Most likely, physicians
kept concrete discussions about prognosis to a minimum because there was a pervasive
belief on the part of the medical staff that vagueness was in the best interest of the
patients. As Rothman points out, the staff in the sanatorium had every reason to avoid
discussions of recovery, for “telling those who were not making progress of their likely
fate was too painfirl, and those who were on the mend might be tempted to leave too soon
or stop adhering to the regimen.”216 But whatever the reasoning behind withholding
information, the inexact terminology used by medical practitioners had the indisputable
effect of creating a type of time warp in which patients had to accept the unknown and
put virtually all of their life plans on hold.

To make matters worse, since many of the patients had a sense a well-being for a
large majority of their stay, they often did not have a good sense of that for which they
should be aiming. Smith describes the struggle of having no concrete goal during her
rehabilitation in the following way, “it seemed to me that convalescence was every bit as
much of a chore as illness itself, and much more boring. When I was severely ill, I was a
least struggling with something immediate and tangible...”217 Realizing that their
subjective feelings were not considered reliable indicators of the true nature of health and

sickness, patients, like Smith, did not have any real or “tangible” indicators of what they

 

2" Smith, 23.
21‘ Rothman, 244.
2” Smith, 132.

81

were fighting, or whether or not they were winning the battle. The uncertainty about how
they should go about attaining their goals of well—being and discharge was acute.
Because patients could not measure their progress, and had to put their plans on
hold, they began to treat days, months, and years with little regard, for not being able to
accomplish anything, the passage of time inside the sanatorium had little meaning. Mann
repeatedly points out the way patients in the sanatorium conflated years into minutes. At
the beginning of the novel, Castorp, who had just arrived to the sanatorium was told that
“three weeks are almost nothing for us up here [in the sanatorium], of course, but for you,
just here on a visit and planning to stay a grand total of three weeks, for you that’s a long
time.”218 In line with Mann’s description, one of the first impressions that MacDonald
had of the Firland sanatorium was the odd way in which sanatorium patients Spoke about
the future. MacDonald writes, “the patients spoke of two, three, and five years with a
casualness usually associated with minutes.”2'9 Once a patient was in the sanatorium
long enough, such an odd tendency frequently became the norm. After a month of bed
rest, Smith claims “I measured my hopes for the future always in terms of ‘next year’—a

practice which became habit.”220

Knowing that the immediate days and weeks would
most likely be taken in bed, Smith began to expect change only in the years to come. In a
way, talking about years as if they were minutes was a means for sanatorium patients to
avoid dashed hopes, to avoid the disappointment that tomorrow would not bring
something new.

From the patients’ perspective, having nothing by which to gauge their days,

weeks or overall progress was something altogether unwelcome. Speaking for many

 

"8 Mann, 7.
2'9 MacDonald, 62.
22° Smith, 55.

82

patients, Smith writes, “The endless passage of days with nothing tangible to Show for it
troubled me more and more. What was I accomplishing—I wanted to accomplish so

much ”221

Patients, like Smith, were put in the paradoxical position of wanting to live
healthy, teleological lives, in which time progressed, but, at the same time, wanting to
adhere to the sanatorium regime which restricted such a life in the hopes for a cure. The
sanatorium regime was thus not at all an easy treatment to endure. No other patient sums
up the sacrifice better than Ross who writes, “...the most difficult thing for a patient to
accept is the fact that he must give immeasurable time—weeks, months, years if need be—

—to his cure.”222

 

’2' Smith, 55.
222 Ross, 89.

83

CONCLUSION
Despite the medical advances made during the 1940 and 19505 and the discovery
of such antibiotics as streptomycin and isoniazid, tuberculosis is still with us today. In
fact, recent evidence indicates that tuberculosis is on the upswing, with various drug-
resistant strains emerging.223 Several studies have shown that much of the drug

resistance to tuberculosis can be traced to the noncompliance of patients taking their

antibiotics?”

Thus today in the United States, the preferred way to control tuberculosis
is through directly observed therapy (DOT), a program in which patients voluntarily
received their daily or twice—weekly antibiotics under the direct supervision of an
outreach worker. Under DOT, patients can received their medications at virtually any
location: at the clinic, in their homes or at their workplace.

But although the DOT program has been rather successful in overcoming
noncompliance rates, there are still some patients with tuberculosis who either refuse or
simply fail to take their medications. In cities and states with particularly high rates of
noncompliance, such patients are often forcibly detained in hospital wards until they are
cured, a practice which is hauntingly similar to the compulsory confinement to sanatoria
in the early part of this century. Yet looking at the issue of noncompliance today through
historically—informed eyes, one can see that much of the problem still lies in the fact that
some patients who do not feel sick have difficulty believing that they are sick or that their

Sickness is threatening enough to warrant medical intervention. For instance, Barron

Lerner recounts a recent case of noncompliance in New York city in which a 34 year old

 

223 For instance, according to Lerner, the annual number of new cases of tuberculosis in the
United States increased by 20 percent between 1985 and 1992, from 22,101 to 26,673. (Lerner,

166) In New York city alone, there was an increase of 2,000 cases between the years of 1980—
1991. (Scale and Pattison, 57)
22‘ Lerner, 167.

84

homeless man with tuberculosis refused to take his medication because he did not believe

he had a contagious, life—threatening disease?25

While laboratory medicine and germ
theory have been with us for over a century now, we still cannot take for granted that
everyone accepts the fact that one can be sick without feeling sick.

Moreover, just as tuberculosis is very much a disease of the present, prolonged
bed rest is still frequently prescribed today. For instance, women with high—risk
pregnancies are often advised to remain in bed, for many physicians believe that a
reduction in activity helps to keep the uterus from contracting. Indeed, some women
have to endure up to four months of complete bed rest. Interestingly, like the sanatorium
patients with incipient, asymptomatic tuberculosis, women with high-risk pregnancies
often have to endure prolonged periods of rest despite their feelings of well-being. For
this reason, there are striking similarities between the contemporary narratives of
pregnant women who have undergone prolong bed rest and the sanatorium narratives—
both convey similar feelings of boredom, isolation, as well as concerns about future life
plans and goals.

A study such as I have undertaken here should keep us from losing sight of the
fact that prolonged bed rest can have serious side—effects on the human psyche. To be
sure, for some of us it is tempting to think of bed rest as kind of vacation fi'om the worries
and tasks of everyday life. And perhaps some physicians today who (with the best
interest of their patients in mind) prescribe prolonged bed rest are still working under the

same premise that Trudeau articulated a century ago: “I know I have hurt nobody by rest,

 

’2‘ Lerner, 167—168.

85

but I am quite sure I often have by allowing them to exercise.”226 But we cannot take the
goodness of prolonged rest for granted. For as we have seen from the sanatorium
narratives, bed rest was so invasive at times that it altered how patients related to the
world around them. In most cases, patients in the sanatorium endured such a deep sense
of isolation that they felt alienated from their families and friends as well as from their

former lives as healthy individuals.

 

22" Trudeau quoted in Pratt, “The Development of the Rest Treatment in Pulmonary
Tuberculosis,” 65.

86

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87

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