Sanatorium- the new type of psychiatric facility
Sanatorium – the new type of psychiatric facility

text and drawings: Krystian Woźniak,
student of Architecture at TU Delft

reading time: around 20 min

At the beginning of the 20th century one of the biggest problem in psychiatry was the increasing overcrowding of its institution. In the late 19th century the most popular architectural model of psychiatric asylum was a cottage plan. Different group of patients, divided by gender, class and the level of calmness where put in separate houses, cottages or pavilions, often in nature. Throughout that time, the design of pavilions, their size or capacity was changing, with a tendency to build more sizeable buildings. Due to the high influx of patients, later pavilions were at least two times bigger Even after building nineteen new institutions up to 1918 and the next nine during the interwar period the problem persisted. At some point, increasing bed provision created a demand leading to rising numbers of admissions. The Dutch government put a stop to the building boom due to the economic recession in 1934. 1

1. Gijswijt-Hofstra et al., Psychiatric Cultures Compared : Psychiatry and Mental Health Care in the Twentieth Century: Comparisons and Approaches.,44

2. J. Vijselaar, "Neurasthenia in the Netherlands," in Cultures of neurasthenia from Beard to the first world war, ed. Marijke Gijswijt-Hofstra and Roy S. Porter, Amsterdam: Rodopi, 2001, 239

The late 19th and early 20th-century asylum was a closed institution, where only people with an officially recognized mental disease could find treatment. In 19th-century psychiatry turned mostly to organic explanations of mental illness. There, anyone who suffered from different disorder, that according to clinic psychiatrists was not caused by organ damage, was eligible for treatment in an asylum. In effect, many of those who suffered from neurasthenia, other neurotic disorders or alcohol addiction, have to look for other places for treatment. Moreover, the degenerationist concept of heredity of mental illness created a negative image of asylums, especially for upper classes, for which any association with mental disroder would damage their social status. Wealthy then tried to avoid associations with asylums and tended to send their sick family members to private institutions, that become extremely popular in the late 19th century.

3. Porter, Madness : a brief history.,87

4. M. Gijswijt-Hofstra, "In Search of Dutch Neurasthenics from the 1880s to the early-1920s," in Cultures of neurasthenia from Beard to the first world war, ed. Marijke Gijswijt-Hofstra and Roy S. Porter, Amsterdam: Rodopi, 2001, 284

These private sanatoria were an outcome of specific ideas, where the rapidly changing world at the time of industrialisation, supposedly caused nervous disorders amongst the upper class, mostly men. They were at that time in the Netherlands regarded as weak, phlegmatic and lacking of moral orientation. 2 The first physician who described neurasthenia was American George M. Beard. For him, the tumultuous environment of the world’s progress resulted in a lack of “nerve force” amongst some people. 3 His ideas were later transferred to Europe and were extremely popular in Germany and Austria. Neurasthenia was less popular at the time in the Netherlands, and although around 1900 there were 19 sanatoria for Dutch sufferers, their total capacity is estimated a little more than 500. Most of these facilities would accommodate a small number of patients. First ones were built in the last 20 years of the 19th century, like small pavilion Rustoord as a part of Veldwijk asylum. 4

There is a link between fashion for neurasthenia in Central Europe and a boom for opening new facilities in the Netherlands after 1900. Dutch, looking for treatment in Austria, Switzerland or Germany, pointed out the demand in their own country. For asylums, providing the service for wealthy nervous patients was an economic advantage but also a way to change an image of the asylum as a closed institution. The amendment to the insanity law in 1904, led to the possibility of creating an open department linked to the asylum. There was no need to have a juridical certification for admission and anyone who could afford care could receive it. Later on also the care for poor in open departments was made possible in 1929 by making the municipalities to pay for their care. These open departments were almost always called “clinics” or “sanatoria”, like private facilities in Germany.

5. Mens, Andela, and Heerze-te Winkel, De architectuur van het psychiatrisch ziekenhuis.,137

6. E. Shorter, ""Private Clinics in Central Europe" 1850-1933", Social history of medicine , 1990,160

7. L. Topp, "An Architecture for Modern Nerves: Josef Hoffmann's Purkersdorf Sanatorium," Journal of the Society of Architectural Historians, 56, no. 4 ,1997,

8. Mens and Wagenaar, Health Care Architecture in the Netherlands,48

Because of this influence, we can use German and Austrian examples as protagonists to the architecture of open departments. We know that architect E. G Wentik, designer of many asylums in the Netherlands like Veldwijk and Christian sanatorium in Zeist (1903) in swiss chalet-style, made prior a study trip to visit few places in central Europe. 5 Edward Shorter describes a wide variety of private institutions there were nervous could seek help. These covers water therapy clinics, spas, sanatoriums, open departments in asylums or clinics. The most crucial figure in those was a doctor who often owned the institution. In their programme, they never offered treatment of mental illness, but a variety of therapies of neurotic disorder or even organic diseases, but in fact, many of their patients were psychotics or hypochondriacs. 6 The clinic owners never wanted to be associated with “classic” mental disorders.

Leslie Topp provides an interesting analysis of Pukersdorf Sanatorium for nervous diseases in Vienna. 7 Its layout and design principles are similar like in later open departments in the Netherlands. The Purkersdorf sanatorium consisted of two short wings joined by central section with the main representative staircase. From outside it looked like a villa. The idea for treating nervous disease consisted of taking the neurotics out of hectic surroundings and chaotic life and placing them in an orderly environment. The day of the patient had a clear schedule full of various activities or therapies. The building layout then supported the regime of treatment with its clear division of spaces for different purposes like sleeping, eating, therapy or leisure. Moreover, the doctors quarter was placed in the central section, underlying his position and simplifying the supervision. Simple layout and glass doors supported constant observation of his clients. These clinics only admitted patients who would entirely submit to doctors guidelines.

Furthermore, the provision of light, fresh air and space was still an inherent element in healthcare architecture and had therapeutic importance. Although now it was to be achieved in one compact building, instead of pavilions in the park in the cottage plan model. 8 Designer of Pukersdorf, Josef Hoffman, achieved this through the implementation of big windows and orientation towards the south. Finally, the use of the newest building technology and elements embodying modernity served in creating an impression of science-based treatment.

9. de Waardt, Mending minds: a cultural history of Dutch academic psychiatry.,129

10. Mens and Wagenaar, Health Care Architecture in the Netherlands., 51

11. J.G. Wattjes, " Het nieuwe gebouw voor de kliniek "Neder-Veluwe" arch.: E.J. Rothuizen," Het Bouwbedrijf 14, no. 16, 1937,151, resolver.kb

12. Mens, Andela, and Heerze-te Winkel, De architectuur van het psychiatrisch ziekenhuis.,135

One of the most popular elements in asylum life was active therapy, adopted at first in Santopoort hospital (renamed Meerenberg, the biggerst 19th century asylum in the Netherlands). The main idea was to prepare patients to return to society by engaging them in all sorts of activities like manual work, singing, dancing and more. 9 The difference from previous work therapy was choosing the activities better suited to a particular patient rather than labour. 10 The therapy also intended to keep patients busy during the day so they will cause fewer problems during the night.

Kliniek Neder-Veluwe

In 1933, the association of orthodox protestants ordered a design of an open section for mentally ill and nerve sufferers for one of their asylums in Wolfheze. The task was assigned to architect E. J. Rothuizen, who previously designed new pavilions for this psychiatric complex. 11 The building, like other open departments in the Netherlands, although falling under administration of asylum, was spatially separated from the primary institution. 12 “Neder-Veluwe was disjoined from the rest of the pavilions by fence, pergolas and greenery. Even its name “clinic” had been breaking any associations with the concept of an asylum. Located near the station and parallel to one of the main roads, the clinic was undoubtedly visible and therefore served as a business card of the Wolfheze asylum.

In layout and design principles, the clinic is similar to other open departments like sanatoriums famous expressionist Noorder Sanatorium by Reitsma. It contains the middle section with wings stretching from it. Central section housing administration and medical services are more representational than the rest of the building, there is a clear division into calm and restless patients and day and night activities, moreover, there are separate spaces - workshops for active therapy. Garden design also receives individual attention.

13. Wattjes, " Het nieuwe gebouw voor de kliniek "Neder-Veluwe" arch.: E.J. Rothuizen."152

In Neder-Veluwe were two main wings running parallel to the road and additional sections were added in front and behind the middle part. The most massive wings contained patients bedroom and dayrooms, staff rooms, isolation rooms, permanent baths, examination and consultation rooms, family visits spaces or spiritual caretake office. The left one housed women and the right one men. The smallest wing, placed in front of the building is only one storey but contain the doctor’s office. The wing behind the middle section contained a kitchen, operation room and several additional rooms for various treatments – the medical section. At the rear, parallel to the main wings were workshops for active therapy, storage and nurse day room. Between the main wings and workshops, two gardens were designed, separated by medical section, for both genders. 13

14. Mens and Wagenaar, Health Care Architecture in the Netherlands., 48

15. Wattjes, " Het nieuwe gebouw voor de kliniek "Neder-Veluwe" arch.: E.J. Rothuizen."153

16. "Nieuwe Zenuwklieniek "Neder-veluwe"," Amersfoortsch Dagblag (Amersfoort), 9.05.1935 1935,

In the architecture of sanatoriums, one of the main principles was the provision of light, fresh air and space. 14 The building’s wings were oriented along the west-east axis, providing as much light as possible from south to the dayrooms and patients or staff dorms. The southern façade is characteristic by its big windows, much bigger than windows on the northern side. Due to safety measures windows were divided into smaller parts. The service functions, isolation or separation rooms or staircases were located on the northside of the wings, as they do not require significant amounts of daylight. The dayrooms had the entire depth of the wing in order to bring the morning and evening light to them. 15 However, they were divided into three sections to group patients according to their behaviour. In order to ensure surveillance, large amounts of glass were used in room divisions, also in dividing the patient’s bedrooms. 16 Big windows allowed ventilation and gardens behind and a park with a pond in front of the clinic provided open space.

Nicole Imrie argues that the architecture of the first sanatoria for nerve sufferers responded to the pace of life and treatment inside and adopted these features from sanatoria for tuberculosis. These aspects include designating each space with different activity – reassembling the patients day. 17 In the “Neder-veluwe” The patient rooms were located mainly on the first floor and the ground floor. Calmer had their spaces closer to the middle section and restless more to the end of the wings. Patients slept in dorms counting around six beds, each. They would spend time in dayrooms or the garden and participate in active therapy in workshops at the back. We can spot a spatial division into different activities, reflecting patients daily routine. Location of doctor’s office at the front of the building middle part underlined his position and consequently treatment regime prescribed by him, feature again fundamental for private sanatoria for neurotics.

17. N. Imrie, "Creating an Appropriate Social Milieu. Journeys to Health at a Sanatorium for Nervous Disorders," in Journeys into Madness, ed. Gemma Blackshaw and Sabine Wieber, Mapping Mental Illness in the Austro-Hungarian Empire, Berghahn Books, 2012, 58

18. Wattjes, " Het nieuwe gebouw voor de kliniek "Neder-Veluwe" arch.: E.J. Rothuizen."153

19. "Nieuwe Zenuwklieniek "Neder-veluwe"."5

20. Wattjes, " Het nieuwe gebouw voor de kliniek "Neder-Veluwe" arch.: E.J. Rothuizen."153

21. ""Nieuwe Zenuwklieniek "Neder-veluwe"."5

The clinic had place for 76 woman and 54 men. Thus, the left wing, intended for female patients, is longer. 18 The reason in this indifference, according to the pre-war sources lies in not in medicine but social relations. A woman could be sent for treatment and leave her family more quickly than men tied to his obligations in work and family. 19 Without a doubt, this reasoning is a result of particular gender roles and relations from that period Whatever this was true or not, as clinic admitted mainly paying patients, we can relate this reasoning to the simple reality of the market, where fewer men decided to go on therapy. In terms of sex division, apart from different wings and gardens for each gender, it was not possible to see from women corridor into men’s one and vice versa, due to intentional misalignment in the plan. 20

The middle section stands out with its height, similarly to Noorder Sanatorium, and by a stained glass window, created by Arnhem artist J.H.E Schilling, how also worked on a stained glass window in another orthodox protestant sanatorium.. The window consists of two parts divided by the main staircase landing. At the bottom, we can see figures expressing the human misery, but at the top, we see a female figure raising her hands towards the light, as an expression of liberation. 21 In the context of the psychiatric institution of Christian origin, this artwork contains a moralistic message – liberation from madness is only possible through the influence of God. On the other hand, we can interpret this as more comforting meaning – the scene on the window functions as a promise of healing.

While design a building architect E.J. Rotshuzien tried to save as many trees as possible to preserve the natural setting of the clinic. The rest became a part of garden design by Otto Schultz, who also implemented a big pond in front of the building. Saving the trees, allowed having a beautiful garden, already at the beginning. 22

22. Wattjes, " Het nieuwe gebouw voor de kliniek "Neder-Veluwe" arch.: E.J. Rothuizen."151

23. Mens and Wagenaar, . 48

24. "De kliniek „De Neder-Veluwe" te Wolfheze Behoorende aan de Chr. Ver. tot verzorging van Krankzinnigen in Nederland," De Standaard, 16.08.1935, 1935,

25.J.G. Wattjes " Het nieuwe gebouw voor de kliniek "Neder-Veluwe" arch.: E.J. Rothuizen," Het Bouwbedrijf 14, no. 17 (1937),

26. "Bijzondere plechtigheid op „Wolfheze”. Afscheid van den geneesheerdirecteur en van den huismeester. Installatie der nieuwe functionnarissen.," De Standaard, Amsterdam, 26.04.1935,

27. Wattjes, " Het nieuwe gebouw voor de kliniek "Neder-Veluwe" arch.: E.J. Rothuizen."155

28. "Nieuwe Zenuwklieniek "Neder-veluwe"."5

No less important was interior design. Van der Scheer, the doctor from Santopoort who introduced active therapy, paid attention to creating a lively, cheerful environment in which patients spent their time. 23 In “Neder-Veluwe walls were painted with watercolour in light and soft tones. The furniture and curtains had the colour of the room where they stood. Furnishing included famous furniture of Viennese designer Thonet, made of bent wooden rods. The factory of famous Dutch designer Gispen supplied the various kinds of lighting with unique safety designs for parts with restless patients. 24 All of this meant to create a cosy, pleasant atmosphere. All materials used inside were easy to clean and maintain. 25

Worth mentioning is the quality of spaces for staff. The Wolfheze asylum long-term director dr. J. Ronda paid particular attention to the quality of working conditions of nurses and wished to make their stay on the institution grounds more pleasant. 26 In cottage-plan model nurses would often sleep almost in the same space with patients. In “Neder-Veluwe” there were staff rooms on the second floor. Each with the access to the loggia on the south side with the view over the village of Wolfheze. The rooms had a pull-out bed, two chairs with a table, sink and wardrobe. 27

Authors of newspaper articles describing the opening of the clinic in 1935 praised its modern look and enumerated all different associations to technology and science. First of all, the “Neder-Veluwe” in plan reminded them of an aircraft, three-decked plane. The section with the doctor’s room was a cockpit, the parts with dorms looked like the wings, the medical section – a cabin and the rear – the tail. 28 The architecture of the clinic do not bring associations of luxury (it was an open department for paying patients but with much lower prices, around 60% of average back then), reporters compared it to diesel train. There, the 3 class client could feel like sitting in 2sc or 1st class, because everything was modern and cutting-edge. 29

29. "De kliniek „De Neder-Veluwe" te Wolfheze Behoorende aan de Chr. Ver. tot verzorging van Krankzinnigen in Nederland."13

30. "De kliniek „De Neder-Veluwe" te Wolfheze Behoorende aan de Chr. Ver. tot verzorging van Krankzinnigen in Nederland."13

31. Mens and Wagenaar, Health Care Architecture in the Netherlands,78

32. "De nieuwe kliniek "Neder-Veluwe" te Wolfheze," Bouw- en Interieurkunst, 26.04.1935, 1935,

33. Mens, Andela, and Heerze-te Winkel, De architectuur van het psychiatrisch ziekenhuis., 147

34. M. van der Beek, Egodocument Beek, 1940-1944, typescript.4­-8

35. A.G. Guttersen, "Mental helth Programs and Facilities in Europe and Asia," in Psychiatric architecture: a review of contemporary developments in the architecture of mental hospitals, schools for the mentally retarded and related facilities: with ass. of e. keenan repr, ed. C. E. Goshen and E. Keenan (Washington: American Psychiatric Association, 1960).. 118

36. Staatsblad van het Koninkrijk der Nederlanden, (Staatsdrukkerij en Uitgeverijbedrijf, 1963)

37. Gemeente Renkum, "Vastgesteld bestemmingsplan ‘Wolfheze 2017’," 2017, 18

Moreover, technological innovations used in a building brought much attention likewise. Media compared cellars to the engine room of a large ship. They mentioned the innovative heating system in isolation cells, which used the flow of hot air rather than radiators, limiting the water temperature in taps to a maximum of 40 degrees to prevent patients from burning. 30 They enumerated all rooms from medical sections, concluding that “Neder-Veluwe” has everything that modern hospital should have.

However, if we look at the pictures of the clinic, we will not see the white, pure, functionalist “hygienic” building. The modernist style seemed to be a perfect match for a healthcare architecture which is determined by its function. The modern movement expressed itself praising the new developments ina society like science, technology, sense of speed. Nevertheless, “Neder-veluwe” clinic, packed with science and technology inside, like many other hospitals and sanatoria would receive more traditionalist look. Noor Mens and Coor Wagenaar pinpoint the reason of modernists failure in hospital architecture to their antagonistic character towards current truths, where modernists where closer to the socialist and communist philosophies. 31 According to articles from the 1930s, the architecture of the clinic corresponded to its architect style. 32 If we look at E.J. Rotshuzien works, we will see buildings following the principles of Amsterdam school as well the style of Delft School later in his work. The “Neder-veluwe” is more traditional in style and more rural at some point, the architect used plenty of natural materials like stone or teak wood. However, the protruding roofs, stripes of high, white windows and red-brown brick design prove inspiration from Amsterdam school. 33 The rural outlook can be as well related to the rural character of sanatoria as health resorts.

The clinic “Neder-veluwe” survived the Second World War despite the bombardment of Wolfheze during World War II, which destroyed some pavilions and brought several casualties. The sanatorium was at that time mostly used by German female communication units from the nearby airport and German troops retreating from France. 34 After war building probably housed older patients from the psychiatric hospital in Wolfheze, what proves the relation of American psychiatrist Alston G. Guttersen from the 1950s 35 and advertisements for elderly caretakers from later years. In 1963 “Neder-veluwe” lost its status as an institution for the care of mentally ill. 36 The clinic was demolished in the 1990s. 37 Probably because of the same reason that led to the closing of many other asylums or sanatoria – the decentralisation of psychiatric care, focusing on outpatient treatment and limiting the number of beds.

38. Oosterhuis and Gijswijt-Hofstra, Verward van geest en ander ongerief: Psychiatrie en geestelijke gezondheidszorg in Nederland (1870-2005), 270


The sanatoria were without a doubt used as a measure to open up asylums, and architecture was used to change public perception of mental institutions. The model of open department follows the model of sanatoria for a nervous disorder, thus breaking up with pavilion typology. It embraced many features of its preceding private institutions like its internal organisation, reflecting the hierarchy in the underlined position of physician and supported surveillance. The active therapy brought new kind of spaces – the workshops. Still for healthcare architecture critical was the provision of light air and space. In a single sizeable building, it required more sophisticated measures than putting a cottage in a park-like setting. To achieve this, the orientation, organisation in plan and the terrain outside should correspond to it. The clinic looked more like a present-day regular hospital, with all its associations to progress and technology and according to Noor Mens or Cor Wagenaar sanatoria were a turning point in the evolution of psychiatric architecture. Unfortunately, the history of psychiatry in the Netherlands shows a different picture. Sanatoria soon became another overcrowded institution for chronic patients or served as an observation ward where patients were transferred later to the asylum. Moreover, the recovery rate in open departments was lower than in regular institutions. 38