Sarah Pearse on Sanatoria in Fiction

Posted on 30th December 2021 by Mark Skinner

Fresh out in paperback, Sarah Pearse's chilling thriller The Sanatorium sees dark deeds perpetrated in an Alpine hotel with a sinister past. In this exclusive piece, Pearse highlights other sanatoria in fiction as well as providing fascinating commentary on the disturbing practices that used to occur in real sanatoria in the past.  

‘An architecture of sublime isolation*.’ For me, this quote perfectly encapsulates one of the big appeals in using sanatoria, or indeed, any kind of institution within fiction: isolation. 

These spaces carry a sense of isolation from the external world, either geographically or simply because of the enclosed environment they inhabit. All institutions tend to have their own rules and hierarchy and over time, become their own society within a society, something that is really compelling to explore in fiction. The themes that arise from this isolation – manipulation, corruption, abuse of power – are rich and varied and make for exciting plotting.

A great example of this is in One Flew Over the Cuckoo’s Nest by Ken Kesey which examines the relationships that develop between patients and staff in an Oregon institution. Randle MacMurphy’s relationship with Big Nurse Ratched is a brilliant representation of the power struggles and abuses of authority that can often occur inside institutions.

With sanatoria in particular, this idea of isolation is taken to an extreme as they were often based in very remote, high-altitude locations for health reasons and to stop the spread of infection. Within my novel, this extreme isolation put my characters, especially Elin, my detective, under pressure and pushed her to her limits. She finds herself without any police back up and in close confines with a group of strangers. She soon becomes part of a new, closed community where seemingly real-world rules don’t apply. We see Elin acting on impulse, making decisions she would never dream of in her day-to-day life. 

This is also very much the case in Thomas Mann’s novel, The Magic Mountain. In the book, Hans Castorp, a young engineer, travels to the Swiss Alps to a sanatorium to visit his ailing cousin. What is meant to be a stay of a few weeks stretches into months, and then years, as Hans himself is diagnosed with tuberculosis and becomes a patient. For Hans, life in the sanatorium is ritualised and rule-bound – a whole new institutionalised world.

Another thing which drew me to setting my novel in a converted sanatorium stemmed from both a fear and a fascination of overtly clinical environments. I have many theories as to why this is, but I think as a patient in any kind of clinical setting, there’s a strange sense of powerlessness – the minute you walk through the door, you are putting your life in the hands of medical staff and for me at least, there’s always a gnawing dread about the fact you have no control about what might come next. 

This idea of powerlessness is something I also found compelling whilst researching The Sanatorium. I was surprised to learn about sanatoria throughout Europe for people classed as ‘morally insane’: in the nineteenth and early twentieth century, many women were placed in medical care for spurious reasons by a male guardian, often diagnosed with ‘Nervenkranke’ (those ill in their nerves). Sometimes this was a guise to take control of an inheritance, or to suppress independent thought and ideas. Some women spent decades being ‘treated’. 

I wanted to explore this theme within the novel (including with my detective, Elin, and how she is treated because of her emotions) and with echoes to the present day where women are still being judged for their feelings. I think the idea that someone might misjudge your mental state and use it, as they did in the past, to institutionalise you is terrifying.

The troubling history of treatment within sanatoria extended beyond mental health. While they often had an admirable goal in mind – healing people – the idea of what was acceptable has changed so much from generation to generation that earlier treatments often seem very experimental or even barbaric. This is exacerbated by the fact that in a sanatorium, everything happens in isolation, well beyond the sight or hearing of other people. 

Imagining what might have gone on in sanatoria past was really the jumping off point for my novel. Several years ago, I read an article in a local magazine about the legacy of tuberculosis sanatoria in Crans Montana, detailing how post-antibiotics some of these were converted into hotels. I immediately started thinking about the darker side of this – how would it feel to stay somewhere that had once been a hospital, a place where many people lived and died? Would any of what once happened still linger and how would my characters feel whilst staying there? 

This idea is another intriguing aspect of using an old sanatorium or any kind of institution as a setting for a novel – exploring how much the history, the energy and malevolent forces of the past might still be lingering despite their current usage. 

In a sanatorium turned hotel, as in my novel, this becomes an even more acute question. The architecture of sanatoria is so atmospheric; they were often designed according to the principles of ‘functionalism’ – the building itself utilised as a medical instrument – large windows, balconies to maximise sunlight exposure, clean, smooth surfaces without clutter so there were less places for germs to hide. This minimalist, clinical design is inherently creepy – a perfect setting for a thriller and something I think any author would want to exploit to heighten tension in a novel. 

In writing The Sanatorium I found that this atmospheric, old sanatorium very quickly became a character itself, a character that neither the guests at the hotel nor the readers can escape, something I think resonates with us all during these endless, strange days of the pandemic.

*A quote taken from Art Historian, Sylvie Doriot Galofaro – from her doctoral thesis by the author, Histoire Culturelle et Representations Transversales de Crans-Montana (1896-2014). Landscapes, Visual arts, architecture, literature and the cinema. 


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