A TUBERCULOSIS SANATORIUM FOR ISTANBUL TURKEY Submitted as partial fulfillment of the requirements for the -Degree of Master in Architecture Massachusetts Institute of Technology W. W. urster Dean of School of Architecture and Planning Massachusetts Institute of Technology may 1947 Celile Berk May 1947 Mr. William W. Wurster, Dean School of Architecture and. Planning Massachusetts Institute of Technology '1 Dear Dean Wurster: I hereby respectfully submit my thesis "A tuberculosis Sanatorium for Istanbul, Turkeyll in partial fulfillment of the requirements for the degree of Master in Architecture. Sincerely yours, Celile Berk V ACKNOWLEDGEMENT I would like to take this opportunity to express my gratitude to Professor Aalto, Professor L. B. Anderson, Professor De Mars, Professor Rapson and other members of the staff of the School of Architecture for their guidance and advice. I wish to thank my Father; the Department of Health in Ankara; Dr. A. S. Pope, director of tuberculosis div- ision, Massachusetts State Department of Health; and, Dr. F. Dawson, superintendent of the Middlesex County Sanator- iu, for the information they supplied me and for their suggestions. I wish to thank all those friends who have been of invaluable help to me in so many ways. A TUBERCULOSIS SANATORIUM FOR ISTANBUL, TURKEY Table of Contents Page THE DISEASE... ................................... 1 Tuberculosis.................. ...........0* Nutrition................................... Housing.. .................................... Occupation...................--------.--.--- 5 War.. ..................... ------. 0....-- ..-- 5 Physical and mentalstrain.................. THE PLACE....................................... 9 Location and environment...... ............. 9 Orientation and daylighting ................ 11 THE RESIDENCE. .................................. 15 The size of the Sanatorium Bed requirements and nursing units......... 15 THE GOVERNMENT................................. 25 The Administration........................... 25 THE CLINIC.. ..... ....................... .... 27 Medical Care................................ 27 Treatment .0 . 6 a. ...................................................... 28 Surgery & .................................................. ..... ... 30 Laboratory and pharmacy............ ......... 32 X-ray and fluoroscopy....................... 33 THE FOOD........................................ 34 The food................... ................ .... 34 The kitchen....................... ......... * 34 UTILITIES..........................*0 &.&................. 36 Laundry....................................*0 0 * * . 36 Heat and Power. * & * * ....................... ..... ... 36 COLOR, MUSIC, MATERIAL.......................... 37 THE COMMUNITY...... ............................. 40 THE PROBLEM ..................................................... ... ... 44 Health conditions in Turkey................. Istanbul..................................... The site of the proposed sanatorium.*....... The Program........................... ... THE LITTLE RED THE DISEASE Tuberculosis Tuberculosis has been called the white Plague. It is a disease caused by the tubercle bacillus, which belongs to the "acid-fast" group of bacteri., some of which are path- ogenic and others quite harmless. But on the whole it has done more devasting work than any other destructive agent. Up to about fifty years ago, the medical profession regarded tuberculosis as an hereditary, non infectious, necessarily fatal disease, and those unlucky enough to con- tract "consumption" as it was then called were expected to die. Even as late as 1886 Hirsch set the number of hered- itary cases as not less than 33.40 to 4o% of the total and stated that contagion played a min~r role in the spread of (1) the disease. In the nineteenth century in England George Bodington gave his patients fresh air every minute of the day and night. This seemed like madness to the drug-con- scious medical corps and his sanatorium was seized and pat- (2) ients driven away. But many years later in Germany the sanatorium treatment of consumption was started by Herman Brehmer. With the help of Humboldt and Schonlein a sana- torium was built in the mountains of Silesia, a sanatorium which still exists. (1) "Modern Attack on Tuberculosis" --Chadwick M.D. and Pope M.D. New York, The Commonwealth Fund 1946. (2) "Medicine Marches on" --Edward Podolsky, M.D. Harper and Brothers publishers, New York 1934 Robert Koch identified the germ in 1882. One of the first rebels against the unsatisfactory kind of treatment was Dr. Edward Trudeau, a New York doctor who had watched his brother's death accelerated by these methods and who upon developing an active case of his own about 1872 went instead to the Adirondack Camp of his friend Paul Smith, mostly to end his days in pleasant surroundings, partly to indulge in the theory that plenty of fresh air and out-door excercise would prolong them. An Adirondack yokul who carried him upstairs to his room said: "Doctor, you don't weigh more than the dried skin of a lamb." But his theory proved good, and from his success with his own case, Dr. Trudeau developed the first successful American treatment of tuberculosis--a prescription of outdoor life and excercise in a high altitude. From a tiny beginning in a two-room shack known as "Little Red", Trudeau Sanatorium at Saranac Lake became the model for hundreds of other institutions. Although a large proportion of the population become infected by the germ at some time, the majority of individ- uals have sufficient resistance to prevent the development of progressive tuberculosis. A world survey shows that tuberculosis tends to be widespread in densely populated areas linked by commercial and social ties with the outside world and is rare or absent in sparsely populated and cult- urally isolated communities. Many people still fail to recognize the disease as a public menace, for they are still ignorant of its dangers and for some reason or another try to avoid going to a hospital. It was found that only 3% of -the Senegalese soldiers summoned to Europe for the first World War were tuberculous, while numerous investigations carried out in the African and Asiatic "colonies and depend- encies" of the European Powers show that primitive tribes living under their natural conditions are almost free from tuberculosis. It has been shown however, that the members of these primitive communities, on quitting their native sur- roundings and coming into contact with the "tuberculized" populations of Europe tend to show a marked susceptibility to tuberculosis. It has also been shown that race is one of the factors for the incidence of tuberculosis. While the jewish race is found out to be almost immune to the disease the negroes are very apt to catch it. "The total death rate for Negroes in the United States for 1943 was 2.75 times that of whites, (1) and was higher in northern than in southern states." One of the major group of factors influencing the course of tuberculosis may be classed as environmental. This in- cludes nutrition, housing, occupation, physical and mental strain, and war, which includes practically all of these hazards. Nutrition The importance of maintaining nutrition in the treat- ment of tuberculosis is mentioned in the earliest records of the disease and today remains as one of the essentials of sanatorium care. A ood example for this is of Denmark in the first World War. (1) "Modern Attack on Tuberculosis"---Chadwick and Pope. New York, The Commonwealth Fund, 1946 Page 27. (2) "The pathogenesis of tuberculosis"--A. R. Rich Springfield, Ill., C. C. Thomas, 1944 Page 224 Heiser The principal industry of the Danes is dairying and meat production, and shortly after the out break of war the demands for these products by the combatant countries resulted in prices which almost completely took them out of the home mar- ke'ts. During this period of three years the tuberculosis mortality rate in Denmark rose over 25%, though the living conditions were practically unchanged. By 1917 the German submarine blockade had cut off practically all of this mar- ket and the Danes were forced to live on their own meat and dairy products. The results were dramatic for in 1918 the tuberculosis rate fell to the prewar level. Housing Although the aggravating influence of bad housing on tuberculosis is generally conceded, it is next to impossible to separate it from the other environmental factors with which it is associated. In short, poverty is the predispos- ing cause of tuberculosis. Overcrowding facilitates the transfer of infection from person to person, and that is pro- bably the significant factor in poor housing. An interesting example for this is the Philippines. The Philippines "usually slept closely together in groups on the floor, they had superstitions concerning the contraction (e$)of the disease and an almost unshakable fear of night air." In such a case curing the people of their superstitions is as great a task as converting them to a new religion. (V) "An American Doctor's Odyssey"---Victor Heiser, M.D. New York W. W. Norton and Company Inc. 1936 Occupation The high incidence of tuberculosis in certain occupa- tion was recognized long before statistical measures of in- cidence were available, and stonecutter's consumption and (1) ootter's asthma were by-words in the respective industries. Certain occupations which involve continued exposure to silica dust carry a high morbidity and mortality from tuber- culosis.