The Walled-in Illness: The Twentieth-Century Finnish Tuberculosis Sanatorium as Lived Space

Abstract

Medical historians have investigated the twentieth-century tuberculosis sanatorium as an idiosyncratic therapeutic tool and environment, while architectural historians have been interested in the development and prominent representatives of the building type. This chapter focuses on patients as active agents interacting with the sanatorium space. Relying on Michel de Certeau’s distinction between space (espace) and place (lieu), the chapter asks how the sanatorium space was used, modified, sensed, and remembered by (former) patients. The primary source material consists of written reminiscences, letters, diaries, and photographs related to and originating in Finnish twentieth-century sanatoria. The chapter argues that the experience of the institutional space formed a key part of the overall sanatorium and illness experience. Furthermore, it demonstrates that the interaction between the patient and the building was less one-directional and more multiform than commonly assumed. Patients described the sanatorium space frequently, and often in highly emotional and sensory terms, but the way they experienced the space was varied and individual. Although the sanatorium was a highly regulated space, patients could use it creatively. They modified the institutional space, often with the purpose of individualizing and de-institutionalizing it, and frequently used it in ways unintended and unforeseen by the medical and architectural authorities.

Introduction

Before the introduction of effective anti-tuberculosis medication in the 1950s, the treatment and prevention of tuberculosis relied heavily on spatial solutions, on moving people from unhealthy or risky places to healthier and less risky locations. At-risk children were relocated to healthy families or placed in preventoria, open-air schools, or summer colonies. For those already ill but deemed treatable, a sanatorium stay was indicated. Hopeless cases withered away at home, in hospitals, or in workhouse infirmaries. The traditional hygienic-dietetic sanatorium regimen was compatible with the dominant medical conception of the complex causation of tuberculosis, but it also reflected age-old ideas about the special healing qualities of certain natural and human-made environments. In the case of the tuberculosis sanatorium, the environment was regarded as therapeutically impactful from the outset, even more so than in the case of other institutions of care.

Medical historians have investigated the tuberculosis sanatorium as an idiosyncratic therapeutic tool and environment, while architectural historians have been interested in the evolution and prominent representatives of the building type.¹ This chapter focuses on the relationship between patients and the building. The primary bulk of source material is constituted by autobiographical narratives written by former sanatorium patients. These narratives were collected by means of a thematic writing competition organized by the Lung Patients’ Union and the Finnish Literature Society in 1971. The resulting contributions—over nine thousand typed and handwritten pages of retrospective narratives—were deposited in the archives of the Finnish Literature Society under the name Collection Competition for Sanatorium Tradition (henceforth ST). In addition to systematically analyzing the ST material, I have made selective use of letters and diaries from other collections, as well as photographs and patient magazines.²

In analyzing the material, I have focused on passages where patients interacted with the sanatorium building—that is, assigned meanings to it, associated emotions with it, misused or modified it, or reflected upon its influence on their social relationships, health, and well-being. “Lived” or “experienced” space is perceived in this chapter as something that is constantly being made and remade in and by such interaction. As Thomas Gieryn and others have noted, buildings are both shaped by and capable of shaping their occupants’ behaviors, social relationships, beliefs, and feelings.³ The chapter argues that the experience of the institutional space formed a key part of the overall sanatorium experience and demonstrates that the interaction between patients and the building was less one-directional and more multiform than commonly assumed.

Sanatoria and Sanatorium Historiography

The tuberculosis sanatorium was a late nineteenth-century innovation designed to treat, isolate, and re-educate people with tuberculosis. In Finland, where tuberculosis mortality rates were among the highest in Europe, a vigorous anti-tuberculosis campaign was launched at the beginning of the twentieth century, and comprehensive public tuberculosis services were put in place in 1948–52. The first specialized tuberculosis sanatoria came into being at the very beginning of the century. During their heyday, between the mid-1920s and the end of the 1950s, sanatoria were a highly visible (and costly) part of the Finnish health care system and a prominent example of state-of-the-art welfare architecture. Specialized tuberculosis sanatoria disappeared by the early 1970s, and tuberculosis services, as a distinct part of the health-care system, were finally dismantled in 1986.

Circa 80 institutions specializing in the treatment of tuberculosis functioned in Finland between 1900 and 1970. They were a mixed bag, consisting of two large private sanatoria, opened in 1903, many small private nursing homes, two state sanatoria, a handful of urban municipal sanatoria/hospitals, some pediatric sanatoria, and 14–16 large “folk sanatoria” owned by municipalities that were collaborating for the purpose.⁴ The variation was also great in terms of architecture. Small sanatoria and nursing homes were usually housed in repurposed wooden buildings, for instance, in old army barracks, farmhouses, and villas. In contrast, major sanatoria were purpose-built establishments designed by leading architects. The bulk of beds were in folk sanatoria, and most ST reminiscences also relate to them. One distinctive feature of Finnish tuberculosis sanatoria was their relatively low level of social segregation. There were no truly exclusive private sanatoria, and class segregation within the institutions was also quite weak. Private sanatoria were struggling charitable institutions rather than thriving business enterprises. Subsidized by the state, they provided a fixed number of free beds to patients with no or little means.

Some studies have focused on the relationship between the sanatorium building and patients. They can be divided into two main classes based on their approach. The first sees the sanatorium primarily as a “salutogenic,” or health-generating, institution. This approach chimes with the original medical rationale of the sanatorium treatment, which relied on the health-promoting qualities of a particular kind of built and natural environment. The environmental rationale waned with the introduction of specific therapies and was largely abandoned by the end of the 1950s. During the past few decades, the notion has re-emerged in architectural discourse, where sanatoria are evoked as historical exemplars of salutogenic architecture.⁵ If the key notion of the first approach is health, the second approach revolves around the concept of power. Inspired by Erving Goffman’s analysis of “total institutions” and Michel Foucault’s notion of “disciplinary institutions,” it sees the sanatorium above all as a strictly controlled environment productive of knowledge and subjectivity.⁶

What the two seemingly different approaches have in common is their tendency to assume the one-way influence—whether beneficent or pernicious—of a stable architectural environment on a passive patient. In an attempt to reinsert patient experience and agency, this chapter relies on Michel de Certeau’s distinction between space (espace) and place (lieu).⁷ As defined by de Certeau, place is static and can be observed as a whole, from above as it were, whereas space is the realm of piecemeal appropriation, multiple meanings, and contingency. De Certeau also characterizes the difference between the two by saying that space is to place as an itinerary is to a map. While place is perceived essentially visually, often from a single vantage point, space is appropriated in action and by all the senses.⁸ In de Certeau’s words, “space is a practiced place,” “composed of intersections of mobile elements.”⁹ It can be claimed that the notion of experience is embedded in de Certeau’s notion of space, which is by definition lived and used.

The term experience has many meanings, ranging from casual everyday meanings (“something that happened to me”) to highly technical psychological and philosophical definitions. I have elsewhere defined experience as “thought emotions” and the historical study of experience as the study of the ways that “people have made sense of their emotions by means of culturally available conceptual tools.”¹⁰ Because experiencing entails meaning-making and because meaning-making is predicated upon former personal and collective experiences and knowledge, there can be no strict distinction between the emotional and the knowledge-based, and experience thus defined is intrinsically historical.

Statements about experiences can concern either speakers’ inner states of mind or outer states of affairs, or both. Either way, they usually entail a claim to veracity and thus a testimonial component: “This is how it was, and I want you to know it.” What they seldom claim is universality, recognizing the perspectival nature of experience: “This is how I experienced it.” ST authors, too, often stressed the veracity of their statements, concerning both inner states and outer affairs, while acknowledging that what they were talking about was their personal take on reality, recollected and recorded to the best of their ability but subject to partiality and error. With material like this, it would be difficult—futile even—to try to arrive at universal conclusions. What we have is an aggregate of voices talking about the spatial parameters of a particular past institution.

Recalling Space

Former patients described the institutional space frequently, often at great length and sometimes in fine detail. This alone seems to point towards the importance of space to their overall sanatorium experience, especially as the list of suggested themes that ST participants were provided with did little to steer their attention in this direction.¹¹ References to space serve multiple functions, both narrative and psychological. Spatial framing is a standard narrative device and a much-used memory aid. To quote the art historian Kirsi Saarikangas, “Space has the power to keep alive, produce and call up memories. There is a strong connection between space and memory, and this connection was central to classical rhetoric and mnemonic techniques.”¹² It has also been noted that people going through personal crises and “biographical disruptions” have a heightened need to anchor their memories to the material world. As the medical anthropologists Kaisa Ketokivi and Mianna Meskus observe, “In the presence of an emotional fear of dispersing into nothingness, the concreteness of material settings emerges as significant.”¹³

The patients’ ways of (re)experiencing and describing the sanatorium space varied widely. This is reflected in the broad range of metaphors they applied when talking about it. They compared the sanatorium to a prison, barracks, and concentration camp, and medical operations and invasive examinations to torture and the Inquisition.¹⁴ The metaphor of a caged bird, longing for freedom, was a much-used rhetorical figure in the poems submitted to the patient magazine.¹⁵ On the other hand, the narrators also referred to the sanatorium as a paradise, palace, grand hotel, rest home, all-inclusive boarding house, and holiday resort.¹⁶ One narrator likened the Halila Sanatorium to a university.¹⁷ An autobiographical sanatorium novel characterized the house as a luxury cruiser, but this was an isolated reference probably influenced by literary models.¹⁸

The medical historian Flurin Condrau has remarked that twentieth-century sanatoria “were no concentration camps; equally they were no cosy Magic Mountains either.”¹⁹ He is no doubt right, as far as external circumstances go, but when we focus on patients’ experiences, the sanatorium was in fact both. What was a magic mountain to one patient was a concentration camp to another, and sometimes to one and the same individual at different stages of their treatment. As many students of space have emphasized, lived space is not singular.²⁰

Judging by the ST narratives, the patients’ first encounter with “the house” left particularly strong memory traces. Addressing this memory-generating quality, a woman wrote about her entry to the sanatorium thirty years earlier: “One surely remembers such days forever. They are, somehow, recorded in the conscious stream of memory, lucid to the last detail.”²¹ Arrival scenes are clustered with negative, emotional adjectives such as “gloomy,” “grim,” “anxiety-provoking,” and “bleak.”²² A woman wrote that she entered the Tampere City Sanatorium believing she would never leave: “I went there climbing the endless stairs leaning on my mother, like a person being accompanied to her grave.” To another ST participant, the sanatorium door seemed like the entrance to a tomb. Some gave the house anthropomorphic features: “The great white house appeared in front of me without warning. It looked hostile, but, at that moment, the feeling was mutual.” Another patient found the sanatorium building, more reassuringly, “calm, perhaps even a little mysterious.”²³

Some entrance scenes convey a sense of intense emotions without using any ostensibly emotional words. Instead, they describe the physical environment in a particularly sharp and distinct way, with the intensity of “flashbulb memories.”²⁴ It seems as if the heightened sensory impressions had taken the place of emotions in these descriptions. Arrival scenes are dominated by visual impressions, but they also evoke other senses, referring, for instance, to the “hospital-like” smell that greeted patients at the front door and that some writers associated with the much-used disinfectant Lysol, others with floor wax or medicines. The strange smell was yet another disheartening reminder that they had entered an alien world.²⁵ The soundscape, too, was occasionally discussed. For instance, people who first entered the sanatorium around noon, when most patients were out on the communal balconies or in bed, might record the eerie silence and emptiness that met them upon arrival.²⁶

Narrators treated in folk sanatoria often commented on the scale of the building, contrasting it with their own modest domestic conditions. They characterized the building as large, huge, grand, and castle-like.²⁷ The stairs seemed “frightfully endless,” the corridor as “long as a city street.”²⁸ A woman admitted to the newly opened Paimio Sanatorium in 1934 wrote: “For a country girl like me, it was a huge experience to come there. The house was big and grand.”²⁹ Some newcomers’ sense of having been thrown into a foreign world was accentuated by their unfamiliarity with modernist architecture and modern conveniences like elevators, telephones, signaling systems, and indoor toilets.³⁰ Many were struck by the excessive cleanliness.³¹ The dissonance between the domestic and the institutional surroundings was relived, in reverse, when the patient returned home: “[At home] Everything seemed so small after the big house.”³²

The contrast between the domestic and the institutional, called forth in many ST narratives, is a reminder of the layered nature of experience and the relationality of lived space. Patients’ recorded experiences upon entering the sanatorium were influenced by the stockpot of their experiences and memories of other spaces, above all their homes, but also for instance schools, barracks, or hospitals. Many patients had also been treated at other sanatoria and would implicitly or explicitly compare one with the other(s).

Spatial Regulations and Transgressions

Goffman and the Foucauldians were not wrong in regarding the sanatorium as a controlled and regulated space. The patients’ use of time and space was indeed strictly controlled, especially during the period ranging from the mid-1920s to the mid-1950s. However, they also found multiple ways of bending the rules and escaping the control.

Entering the sanatorium, patients were met with a confusing array of rules and regulations. Kaarlo Aitamäki, who was treated in Paimio in the 1950s and again in the 1960s, calculated that the rulebook he had been handed when he was first admitted contained over 200 dos and don’ts, mostly the latter. He described his frustration in a letter to a friend:

In this house, patients are barred from many places. In general, you can only move in your own ward and its corridor at certain hours—unless you are a bed patient—and likewise in the day room and games room and dining room and in the communal balcony [halli] during the open-air rest hours. Patients who are well enough can take walks outside at fixed times. […] Anyone who has been here a few months […] will start to feel anxious and start thinking it is a prison, although of course it isn’t.³³

The rules, which could be complex and reach down to the minute details of everyday life, mainly pertained to the use of the sanatorium space. For instance, rules regulating the use of the elevators were intricate: how many floors patients were allowed to travel by an elevator depended not only on their physical state but also on whether they were going up or down. (In practice, it might also depend on the social status of the patient, and their relationship with the staff.)³⁴ In addition to the written rules, there was a multitude of unwritten ones. Successful institutional acculturation required that the patient learned to “see” the intramural divisions and boundaries and to respect them.

House rules and the architecture conspired to stabilize social relationships and hierarchies and regulate the distance between different classes of people inhabiting the sanatorium—staff and patients, adults and children, and, above all, men and women. Sanatorium architecture, too, reflected the importance assigned to gender segregation: in large traditional sanatoria, male and female wards and communal balconies were distinct structures, placed on the opposite sides of the building (Fig. 9.1). In 1913, a physician was planning to open a private sanatorium and sent the floor plan for review to the deaconess she wanted to recruit as matron. One detail drew sharply critical comments from the latter: the mixed communal balcony. Such a structure was asking for trouble, she argued, for patients would seek sexual gratification by any means, and design solutions must make this as hard as possible. “You cannot even fathom what our common people are like,” exclaimed the deaconess.³⁵

Fig. 9.1

Satalinna Sanatorium in Harjavalta. (Photographer unknown, the archive of the Finnish Lung Health Association, Helsinki)

As the wording of the matron-to-be indicates, gender segregation intersected with class considerations, particularly during the first part of the century. Middle-class medical directors and matrons self-evidently assumed that working-class people lacked self-restraint in sexual matters. Therefore, the greater the number of public patients in an institution, the stricter was the gender segregation. The few larger sanatoria that had mixed-sex communal balconies or wards were comparatively genteel. The Nummela Sanatorium, the closest thing to an elite sanatorium in Finland, had some mixed wards, and the male and female sections of the communal balcony were separated by a light partition only. The Halila Sanatorium had two separate buildings for adult patients; the building reserved for private patients had mixed wards, while the building housing both public and private patients did not.³⁶

Just like the rules mainly concerned the proper use of the institutional space, rule-breaking often took the form of spatial transgressions. Patients found multiple ways to trespass on the visible and invisible borders separating different groups, especially those between men and women. “String elevators” (naruhissi) were used to deliver messages and gifts between male and female rooms, wards, and balconies. Men visited women in their rooms and balconies during restricted hours, and male patients were reported having sneaked into nurses’ quarters.³⁷ While men and women were allowed, even encouraged, to associate with each other under certain forms (called “lumpustaminen” in Finnish and “cousining” in American sanatorium slang), sexual relationships were proscribed by the rules and discouraged by the staff. Patients, however, were proficient in making use of the sanatorium space for intimate encounters. Judging by the ST narratives, patients engaged in sexual acts in closets, stairways, storerooms, wardrobes, elevators, behind curtains, or basically any little used and ill-lit corner of the institutional space, as well as on the sanatorium grounds.³⁸ It might be difficult to associate such feverish exertions with people institutionalized because of a serious chronic disease. However, it should be remembered that the largest age group in traditional sanatoria consisted of 15–25-year-olds, and the majority of patients were mobile rather than bed-ridden.

The term “sexual acts” should be understood in its broadest and vaguest meaning here. There is really no way of knowing how common such encounters were or what they entailed. What is clear is that the sanatorium emerges as a much more promiscuous place in the men’s than in the women’s narratives. Obviously, gendered cultural norms and expectations are at play here. It was socially more acceptable for men to actively defy house rules and transgress spatial and social boundaries in search of sexual pleasure. As Condrau has noted in discussing German sanatorium patient subculture, male patients were under considerable peer pressure to show an interest in women despite their illness.³⁹ This is clearly true for Finland as well. It is fully possible that some men still felt the weight of cultural expectations and peer pressure when they penned their sanatorium experiences, which made them accentuate (or make up) sexual reminiscences. For women, the social pressure and expectations went the opposite way, making them more likely to downplay or omit sexual acts and thoughts when recounting their sanatorium memories.

Not all spatial transgressions had to do with sex. Patients violated spatial boundaries for other reasons as well, for instance, to alleviate boredom or for material gain. An athletic male patient would use the fire ladder to leave the sanatorium to buy alcohol, which he then sold to fellow patients. A woman treated at the Muurola Sanatorium as a teenager made use of the scaffolding—the sanatorium was being enlarged at the time—to climb to the roof “to see the world.” Another teenage girl escaped the sanatorium routine by exploring out-of-bounds zones until she accidentally ended up in the morgue, almost getting stuck there with a fresh corpse. A twelve-year-old girl, treated at Takaharju Sanatorium at the beginning of the century, sneaked out at nights just to walk and run on the forested ridges surrounding the secluded sanatorium.⁴⁰

Adult patients caught in the wrong place at the wrong time could be reprimanded or discharged. In ST narratives, by far the most common reason for a disciplinary discharge was drinking. Drinking often took place in the woods surrounding the sanatorium and thus involved spatial transgressions. The decision to discharge a patient was made by the chief physician, and there was no court of appeal. To other patients, these decisions could seem arbitrary and cruel, especially when the patient ousted from the sanatorium was very sick or homeless.⁴¹ The Second World War brought many young servicemen, and with them new disciplinary problems, to sanatoria. However rowdy, a sick serviceman could not be sent home. At least one chief physician solved the problem by having a lockup installed on the premises.⁴²

On special days and occasions, spatial rules were temporarily relaxed. Patients could roam freely from ward to ward after the normal curfew on Christmas Eve, Christmas Day, and New Year’s Eve.⁴³ First of May celebrations included carnivalesque elements and forms of ritualized opposition. Patients wore fancy dress and organized a mock demonstration that involved marching, chanting, and signs with assorted demands.⁴⁴ In Meltola Sanatorium, this ritual exceptionally took place on the chief physician’s name day rather than on the First of May, but was otherwise true to form:

With noise and clatter the long procession of patients curled down to the physician’s house early in the morning. With soot and paint on their faces, all dressed up and masqueraded, carrying protest signs. On the signs one could read: “Down with medical power,” “Put milk in our jugs,” “Freedom from work,” “Freedom from the halls,” “Long live card games,” “We demand” and many other things. […] He came to the balcony and observed the spectacle and received our congratulations. It was play, but maybe with a bit of oppositional attitude mixed in. He would point at the people with the protest signs and state: “She will be exempted from the hall today,” “He won’t have to work,” and “she shall have milk in her jug,” etc. The funny thing was that none but the one who carried the sign was given the privilege. And for that day only.⁴⁵

De Certeau’s term “oppositional practices” captures the nature of patients’ transgressions better than Foucault’s rather demanding “resistance” or Goffman’s functionalist “secondary adaptation.”⁴⁶ Patients did not participate in organized efforts to overturn or undermine the established order. Rather, they engaged in small, mundane acts that went against the intentions of doctors, administrators, and architects, introducing a degree of instability and unpredictability to the regime. Their motives varied a great deal. Especially with younger patients, such practices approximated (team) sports, a cat-and-mouse game that offered more excitement and distraction than organized pastimes. Oppositional practices alleviated the tedium and the feelings of fear, powerlessness, impotence, and alienation that accompanied prolonged sanatorium treatment.⁴⁷ A war-time patient summed it up as follows:

Generally speaking, it was like a party, the comradeship and the mood were usually high and good. (It should be remembered that I was there as a bachelor and as a young person.), for example, all sorts of little mischief, the kind that young people get into, like going to the village and the like, having girlfriends (cousins), etc. and everything that differed from normal life, was interesting. I don’t really [want to] recall the medical side of it.⁴⁸

Patients Molding the Sanatorium Space

The built environment was not stable, and the interaction between the building and the patient was not unidirectional. Patients acted on the sanatorium space by domesticating and individualizing it, for instance by creating small domestic islets. These were often centered around a substance, and they tended to be homosocial.

Coffee was clearly a substance capable of bringing people together and answering not only physiological but also psychological and social needs. Patients placed cooking plates and electric pots in their rooms and other corners of the wards. Both men and women brewed and drank coffee, but coffee has been a particularly central part of female sociability in Finnish culture, and it was so in the sanatorium as well. Female patients communicated many fond memories of making and drinking coffee, while men referred to these activities only in passing.⁴⁹ For women, coffee-drinking was an occasion for social bonding and a respite from the rigid sanatorium regime. A woman who had been treated in one of the smaller sanatoria as a girl wrote:

Then I remember a man called Aabraham Kalliokoski he might have been around 40 or little older, I thought it was exciting to sneak to visit Aabraham he namely boiled coffee in the oven of a room [that was seldom used], and I also got a cup if I did not tell anyone, it was probably not quite allowed by the sanatorium rules at the time, the coffee, it weakened your appetite. That man Aabraham was a sort of a father figure for me which is probably why I liked him so much, fatherless as I was.⁵⁰

More commonly, women brewed and enjoyed coffee among themselves. A woman recaptured the pleasure of drinking coffee together with fellow patients in the evenings when the lights had been turned off in the room and the only light came from the lamppost outside. She grew so used to this comforting ritual that she found it difficult to go to sleep without it.⁵¹ Emotions associated with coffee in ST narratives are almost exclusively positive. The only exception I have come across is a piece in a patient magazine where a man suspected that women gossiped about men over their coffee.⁵² This piece of writing, too, indicates that collective coffee-making and drinking was regarded as a gendered preoccupation.

Men, in turn, created partly clandestine, homosocial spaces around smoking and drinking. When smoking was still formally prohibited in sanatoria, men would sneak into a toilet at night to smoke and talk. A male narrator described the smoking room as a place where you learnt to know men from other wards and could talk about anything, including politics and religion, topics otherwise proscribed by sanatorium rules. Another noted that lewd talk was even more common in the smoking room than elsewhere in the sanatorium.⁵³ The issue of smoking also allowed men to “stand up to the big man.”⁵⁴ In the 1950s, patients and patient associations campaigned against the smoking prohibition, and smoking rooms were indeed installed in central sanatoria.⁵⁵ These rooms remained characteristically male spaces even after that. There must have been women who smoked, but women produced no first-hand reminiscences about smoking or smoking rooms.

There were also other ways in which patients could individualize and “domesticate” the institutional space, for instance, by means of their personal belongings and images. Written narratives seldom refer to personal items, perhaps because the authors did not think that these counted as “tradition”—that is, they had no ethnographic or historical information value—and they are also absent from photographs taken for promotional purposes. In contrast, snapshots taken by patients and staff do include personal items and ad hoc decorations.⁵⁶ Snapshots show how patients could mark a little zone as their own by means of personal items (Fig. 9.2). In a snapshot taken in the male section of the communal balcony of the Nummela Sanatorium, the wall was decorated with cut-outs of pin-up girls. Such embellishments individualized the space, marked it out as homosocial, and, to the extent that the images annoyed the nursing staff, provided a way to engage in minute oppositional practices (Fig. 9.3).

Fig. 9.2

Patients of the Satakunta Sanatorium by their nightstands. (Photographer unknown, the image archives of the Finnish Literature Society, SKS 8508:004.)

Fig. 9.3

Patients in the male part of the communal balcony of the Nummela Sanatorium, Nurmijärvi. (Photographer unknown, the image archives of the Finnish Literature Society, SKS 8014:3.)

Naming practices can be regarded as another way of individualizing and de-institutionalizing the sanatorium space. Patients habitually gave nicknames to the sanatorium and its parts. These could be private, as for instance when a young woman called the loathed Nummela Sanatorium “satanorium” in her letters.⁵⁷ More commonly, however, nicknames were part of the shared patient subculture. To give but a few examples, the smoking room was known as “the gas chamber,” the corridor leading to the operation room as “the alley of suffering,” and the waiting room for the doctor’s office as “the fish trap.” The room to which the bodies of freshly deceased patients were taken was called “the three-mark bedsit,” apparently because it cost the relatives three marks to reclaim the body. The outdoor privy located in the far corner of the grounds of the Oulainen Sanatorium was known as Helsinki, in “honor” of the faraway southern capital.⁵⁸

Nicknames, like the sanatorium subculture in general, were saturated with black humor. Humor was a way to address and share emotions, perhaps above all fear, without having to name them directly. This is obvious when space-related names were used metonymically in talking about death: in the Muurola Sanatorium, “moving to the cellar” meant dying from the disease, and, in Paimio, references to the “Rose Cellar,” the sanatorium morgue, served a similar function.⁵⁹

Isolation and Communality

Space organizes social relationships, and social relationships shape experiences. To illustrate this, I will next discuss two parts of the sanatorium space with special medical and social functions and meanings: the isolation room and the communal balcony. They epitomize the combination of enforced isolation (from the outside world) and intense communality (within the institution) that was so characteristic of the traditional sanatorium.

The value attributed to privacy varies over time, from culture to culture, and from one person to another. Sanatorium patients were hardly ever alone. They shared a patient room, ate together by long tables in a communal dining room, and took their open-air treatment side by side on a communal balcony. No room used by the patients, not even the toilets, could be locked from inside.⁶⁰ Self-isolation was both difficult in practice and poorly tolerated socially. An effort to self-isolate was likely to be interpreted as a sign of incipient depression and countered by a collective effort to cheer the person up.⁶¹ While patients may have disliked this lack of privacy, they mainly accepted it as an inescapable fact of sanatorium life. Coming predominantly from small farmhouses and working-class homes, they did not expect life indoors to be anything but communal and—by present-day middle-class standards—cramped. Sleeping several to a room, or even to a bed, was a rule rather than an exception in mid-century Finland.⁶² Single people seldom lived alone either.

In folk sanatoria, not even money could buy you privacy. Patient rooms usually slept two to four. (Large communal wards were only found in pediatric sanatoria.) Space was economically employed, with smallish rooms and little space between the beds. The sanatorium diary of a woman treated at the Paimio Sanatorium during the Second World War conveys the stress that this enforced proximity could engender. The diarist was a Finnish-speaking, middle-aged, working-class mother of two. She shared a small twin room with a Swedish-speaking seventeen-year-old girl with advanced tuberculosis. They lay on their beds, close enough to touch, without a common language, day in and night out. At night, the diarist was kept awake—in a growing state of anxiety—by the incessant coughing, labored breathing, and feverish moans of her roommate. Both patients improved when the girl was finally moved to another room and got a roommate she could talk to.⁶³

By and large, ST narrators did not associate single rooms with privacy or luxury but with loneliness, deterioration, and approaching death. Some shuddered at the recollection of the time they had been temporarily left without a roommate, because it had allowed them to surrender to their anguish.⁶⁴ In folk sanatoria, private rooms were reserved for critical and terminal patients, and the expression “room of one’s own” was used as a shorthand for death or the terminal phase of disease.⁶⁵ In the Satalinna Sanatorium, the single room reserved for terminal patients was known as “the death cell.” Rooms for terminal patients were also called “glass closets” or “glass cells,” because their inner doors had a window through which the patient could be observed.⁶⁶ A young woman who had seen her boyfriend taken to the “glass closet,” never to return, had no illusions when she was placed there herself a few years later. She recorded in her diary that she was reconciled with the idea of imminent death but was nevertheless vexed when fellow patients, including people who had never paid her any attention at the regular ward, visited the glass closet to solemnly bid her farewell. She relished their amazed expressions when she was able to leave the “glass cabin” for a short walk in the corridor.⁶⁷ One was not expected to leave the room, not even temporarily.

In pediatric sanatoria for extrapulmonary tuberculosis, isolation rooms had somewhat different functions. They were occasionally used to house terminal patients, but more commonly to quarantine newcomers, to isolate children with acute infectious diseases, and to mete out punishments. A man admitted to a children’s sanatorium in Sweden at the age of four had positive memories of the “iso”: isolated there due to mumps, he welcomed the change and especially the special attraction of the room, a private radio with headphones.⁶⁸ More commonly, memories relating to isolation rooms are negative. A woman still vividly recalled her dread when she had first been admitted to the Salpausselkä Pediatric Sanatorium at seven, strapped to an isolation room bed, and left there for two weeks.⁶⁹ Another narrator had been taken in his bed to the isolation room as punishment and left there alone without light, food, drink, or any idea about how long he would have to stay.⁷⁰ Isolation was also a common punishment for not eating everything on one’s plate (feeding was a high priority in pediatric sanatoria).⁷¹ Reading these narratives, the limits between punishment, treatment, and prevention seem blurred to the present-day observer, as they did to the erstwhile child patients.

The communality of sanatorium life is epitomized by communal balconies, the architecturally most characteristic feature of the traditional sanatorium building. In English literature, these structures are discussed under many names, including sun-terrace, external dormitory, sunning deck, cure gallery, cure balcony, loggia, treatment balcony, and Liegehalle.⁷² In Finnish sanatorium language, one and the same word, halli (from the German Liegehalle) referred to three things: an architectural structure, a social unit, and a period of open-air treatment. Architecturally, the typical halli was a long, narrow, roofed structure facing south. It was located on the opposite side of the building from the entrance to keep visitors from disturbing the patients resting there. In purpose-built sanatoria, the communal open-air rest halls (i.e. halli) were an integral part of the building and accessible from inside, while buildings repurposed as sanatoria might have separate, self-standing halls. Socially, it was the hall rather than the ward that was the main arena of patient subculture.⁷³

The communal balcony was also a therapeutic space, where fresh air was dispensed like a medicament to the patient, supposedly at rest. As soon as patients were fever-free, they were “given the halls”—that is, prescribed one to three daily outdoor rest periods. In traditional sanatoria, patients might spend up to five hours a day on the balcony. Patient experiences relating to the hall hours were, again, varied. The so-called silent hour, the rest period during which patients were not supposed to move or talk, especially divided opinions. Some appreciated being left alone with their own thoughts or getting away from their roommates for a while. Some recalled beautiful sights or pleasant sounds associated with the surrounding woodland. Others remembered being cold, disturbed by unpleasant noises or smells, or bored to the extreme.⁷⁴ A woman who had been treated at the Tampere Sanatorium in her early twenties recalled the rest hours, when patients were lying “side by side silent like mummies,” as the most oppressive part of her generally stunted and “completely institutionalized existence.”⁷⁵ In the 1960s, many central sanatoria demolished their communal balconies or converted them into indoor spaces. In what now seems like a symbolically loaded act, the sanatorium building closed upon itself, renounced its “porous” structure together with its characteristic forms of treatment and communality, and became indistinguishable from other institutions of care.

Conclusions

It is fully possible and legitimate to study the sanatorium as a meticulously designed, completed, static place (in de Certeau’s sense), and this perspective has indeed dominated sanatorium historiography. The sanatorium as a place can be reconstructed based on plans, drawings, project descriptions, rulebooks, and administrative documents. What emerges from such studies is a functionally differentiated and strictly rule-bound institution whose outer and inner boundaries are sharp both spatially and socially.⁷⁶ The sanatorium rules, overseen by the medical and nursing staff, pulled in the same direction. They segregated women from men, children from adults, patients with different forms of tuberculosis from each other, and the staff from the patients.

Looked upon as a space, as I have done here, the sanatorium emerges as a more muddled, ambiguous, and mutable institution. Patients were not just guided, constricted, and molded by the built environment; they also interacted with it, thereby influencing their own sanatorium experience. They invested the sanatorium space with divergent and sometimes surprising values, meanings, and emotions. They found ways to bend the rules and to use and modify the institutional space in ways unrelated to and unforeseen by architectural and medical experts, to better meet their emotional and other needs. Men and women met in places they were not supposed to meet, children were treated among adult patients, (middle-class) patients socialized with doctors and nurses, nurses became romantically involved with patients, and, not infrequently, members of the staff turned into patients and vice versa. Patients’ “oppositional practices” destabilized the sanatorium rule without a coordinated attempt to reverse it. The textual and visual documents produced by patients allow us to study the sanatorium as a space in a way that plans, blueprints, and administrative documents alone do not.

Methodologically, these observations cast some doubt on the idea that “the construction of the patient” could be exhaustively studied by analyzing medical or architectural intentions as expressed in architectural drawings, project plans, or in-house regulations. Experiencing the site first-hand today is no royal road to capturing the historical experience of the same space either. A well-preserved building may be the same place, but it is not the same space to, say, a seriously ill patient who was admitted to the sanatorium in the 1920s with a potentially fatal disease and stayed there for years, to an urban explorer seeking thrills in a derelict former sanatorium, to an enthusiastic architectural tourist visiting a cultural heritage site, or, for that matter, to a historian chasing past patient experiences.