How a Portuguese Village Gained Fame: Caramulo TB Sanatorium Resort

The Grand Sanatorium, one of 20 units, around 1930 (Photos by Diário da República from Expresso)

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At the beginning of the 20th century, Caramulo was only a few houses and as many buildings for commerce and the accommodation of patients convalescing from tuberculosis and other debilitating disease.

By mid-century, what became a village in the Serra do Caramulo mountains, in Tondela Municipality, attracted thousands of tuberculosis sufferers from Portugal and the rest of Europe to the Caramulo Sanatorium Resort, the largest such center on the Iberian Peninsula, reported Público (April 15, 2018).

"Tuberculosis is a word with enormous social and individual weight, a disease that, as José Avelãs Nunes, (author of Arquitectura Branca: Os Sanatórios para a Tuberculose em Portugal, 2022), reminds us 'ravaged a large part of the Portuguese population. It killed thousands of people, with rapid contagion, without choosing social strata. It was linked to apparent opposites, from alcoholism or prostitution, to the most romantic and elitist views. It decimated entire families.

"Besides being very visible through the physical expressions of the patient, pale and consumed (thus, the name consumption), the white plague was a prognosis of death." Consequently, the patient was exposed and a victim of violent segregation", reported Diário de Notícias (June 19, 2024).

Dr. Jerónimo Maria de Lacerda (1889-1945), founded the Caramulo Sanatorium Resort. He was the son of the sub-delegate of health in Tondela, a town where he had spent his childhood and knew well that region of Viseu District, according to Expresso (March 22, 2023), in an article written by António José Barros Veloso (1930-2025), who specialized in Internal Medicine and Oncology and whose father worked at Caramulo "his whole life" as the director of the analysis laboratory, according to Ordem dos Médicos: Região do Sul. Veloso wrote The Rise and Fall of a Tuberculosis Resort (2010).

In the Expresso article, we learn that Jerónimo Maria de Lacerda had big dreams, determination and an "undeniable charisma", which helped him forge "a vast network of friendships among politicians and people in high finance".

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(Left to right) António Ferro, a writer and a major force behind the cultural and propaganda policies of the Estado Novo regime, António de Oliveira Salazar, architect of the Estado Novo, which ruled until 1974, and Dr. Jerónimo Maria de Lacerda, founder of the Caramulo Sanatorium Resort

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His father, Abel Maria de Lacerda, sent him to the University of Coimbra, where he had studied, and his son excelled, graduating in 1915 in Medicine and Philosophy with 19 out of 20 points, according to Jerónimo de Lacerda e o Caramulo, Instituto Nacional de Saúde Doutor Ricardo Jorge.

The same year, Professor Elísio de Moura, who distinguished himself in Psychiatry and Neurology, invited him to be an assistant at the Faculty of Medicine. The following year, Jerónimo Maria earned his doctorate.

During the First World War, the young physician was called to Angola and eventually sent, as a doctor in the Portuguese Expeditionary Corp, to the battlefront in Flanders. He returned to Portugal in 1918, when he began his focus on the treatment of tuberculosis.

What Is Tuberculosis?

Tuberculosis (TB) mainly affects the lungs, but it can spread to other parts of the body. It is caused by a bacterium called Mycobacterium tuberculosis, also known as Koch's bacillus. It can spread when a patient coughs, sneezes, laughs, speaks or sings, introducing tiny droplets into the air. Another person can breathe in the droplets, and the germs enter the lungs, according to the Mayo Clinic. The symptoms, which usually worsen over time, include coughing, coughing up blood or mucous, fever, chills, fatigue and weight loss.

"Pure air, rest and abundant food" constituted the formula for treating tuberculosis for decades in the 19th century. In the 20th century, isolation was added to that formula. Calcium and gold salts had proven ineffective, according to Expresso. There would not be effective drug therapies until the 1940s.

Since the beginning of the 20th century, the Serra do Caramulo was known for its "good air", welcoming "guests with weak" lungs to its homes, according to Jerónimo de Lacerda e o Caramulo.

However, access was difficult. There were no municipal or state roads in the mountains.

Caramulo Society Supporters

Jerónimo Maria de Lacerda founded the Caramulo Society in December 1920. About two years later, it opened its doors of its Grand Hotel, reported Público (April 15, 2018). At that time, the negative connotations of tuberculosis and the word "sanatorium" were being avoided, and it was not yet known that this could be the ultimate purpose of the space.

Presiding over the society's first meeting was Guilherme Alves Moreira, professor at the University of Coimbra Faculty of Law, who eventually held the longest tenure of president at Caixa Geral de Depósitos, according to the bank's website.

Attendees of the Caramulo Society's had illustrious professional reputations, such as António Egas Moniz, who would receive the Nobel Prize for Medicine in 1949 for "the discovery of the therapeutic value of lobotomies in certain psychoses"; Elísio de Moura, Lacerda's former teacher who would become the first president of the Portuguese Medical Association in 1939, and José de Castro Côrte-Real, Count of Fijô, Aveiro District, and administrator of the Portuguese Bank of the continent and Islands and of the Colonial Development Company), according to Jerónimo de Lacerda e o Caramulo.

Fernando Bissaya Bareto, professor of Medicine at the University of Coimbra and surgeon also supported Caramulo. Luís Quintela, the first Portuguese thoracic surgeon, would travel from Lisbon to Caramulo on weekends for operations, reported Expresso (March 22, 2023). There, he acquired much experience in various techniques in vogue, such as collapse therapy -- pneumothorax and rib-cutting, collapsing the affected part of the lung by removing segments of several ribs and promoting healing by "resting" the organ.

Lacerda also sought support from figures in Lisbon, where he made frequent visits. In the 1930s, he developed a friendship with António de Oliveira Salazar, then Minister of Finance, but whose authoritarian Estado Novo would rule the country until 1974.

"Salazar . . . was experiencing weight loss, insomnia and migraines. His friends, concerned for his health, advised him to seek the fresh air of Caramulo and the advice of Jerónimo Lacerda. (The doctor) offered him a chalet to rest in, which Salazar accepted but rarely used," reported Expresso.

"While no serious health problem was confirmed, the meeting between Salazar and Lacerda, nevertheless, forged a strong friendship which lasted a lifetime and extended to other members of the family. When he went to (his home village) of Santa Comba Dão (in Viseu District), Salazar would visit Caramulo, where he often attended Sunday Mass. Lacerda and his family gained easy access to the Prime Minister's residence, which they visited frequently. Furthermore, Salazar was always present during several difficult times for the Lacerda family."

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Caramulo Sanatorium patients resting, around 1930, in a gallery where a film projection screen is fitted for films

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The Grand Sanatorium grew into a sanatorium resort of 20 units, some of which were state-owned, but all under the control of Lacerda, who had bought land and engineered infrastructure.

The Caramulo Society built a water distribution network, dam, sewage and waste treatment system, structure for the recovery of contaminated water, post office, telephone exchange, slaughterhouse, primary school, and an incineration center, reported Público. The society also paved a road to Campo de Besteiros, a village about 160 kilometers (99.4 miles) away and about 8 kilometers (5 miles) outside of Tondela.

In the Great Sanatorium, an enormous three-story building with two side wings, attics and surrounding galleries, there was a clinical analysis laboratory, radiology service, central pharmacy, stomatology clinic, dishwashing sterilization area and an operating theater. There were libraries, game rooms, a giant screen, where the newest films were shown and, later, a movie theater.

To help erase the stigma of tuberculosis, Lacerda beautified the area. He initiated a reforestation program, created access roads to the mountain areas with panoramic views of the valley, and he founded a tourism board, only the second in the country after that of Estoril, according to Expresso.

With the Spanish Civil War (1936-1939) and, then, the Second World War (1939-1945), many tuberculosis patients from large European sanatoriums came to Portugal, according to Público. In 1928, the Grand Hotel became known as the Grand Hotel Sanatorium. In 1933, it became simply the Grand Sanatorium.

In the 20th century, in Portugal, there were 11 sanatoriums, according to the website of João Gago, a photographer, one of whose pictures of his project of the Sanatorium of Covilhã, in the Serra da Estrela, graced the front page of Destak.

As the white plague consumed the country and Europe, the number of tuberculosis patients admitted to Caramulo increased year after year, In the early 1930s, official statistics cited 13,000 deaths annually in Portugal. In 1930, the national population was 6.8 million, according to the Instituto Nacional de Estatística.

The Caramulo Sanatorium began to receive patients referred by the General Directorate of Assistance, Armed Forces, and Railway Workers in addition to private patients, reported Expresso.

Caramulo Became Cutting-Edge

In 1938, Manuel Tapia, director of the Fuenfria Sanatorium in the Sierra da Guadarrama mountains. in Spain, and representative of a brilliant generation of Spanish doctors, decided to leave the atmosphere of terror in Madrid around the Civil War. He settled in Lisbon, met Jerónimo Lacerda in the hotel where they stayed, and accepted the offer to be the Scientific Director of the Caramulo resort.

Tapia, a prestigious phthisiologist, who is a physician who specializes in the care, treatment and study of tuberculosis, got to work quickly. He reorganized clinical services, created an archive of medical records and radiographs, as well as promoted weekly meetings of the medical staff.

In his first year, he brought together 300 Portuguese and Spanish doctors for eight days in Caramulo. Theoretical and practical courses were organized for small groups of doctors. These initiatives were remarkable, for the time, especially since the institution was private with no academic connection.

Caramulo became a reference point for treatment of tuberculosis and the destination for patients from Portuguese high society who had been barred from accessing other European TB resorts after the outbreak of World War II. Doctoral students and university professors sought clinical material and advice for their theses and dissertations there, including such well-known figures in Portuguese medicine as Thomé Villar, Machado Macedo and Eduardo Esteves Pinto, according to Expresso.

Jerónimo Lacerda's Dies Suddenly

In 1945, Jerónimo Lacerda died suddenly of a heart attack. His eldest son, Abel, succeeded him in managing the resort. His youngest son, João, would take on the role of Clinical Sub-Director a year later, after completing his medical degree.

The resort was at its peak: 20 inpatient units, 32 doctors, 1,200 patients and "a prestige that was never tarnished by the dubious and never proven effectiveness of the therapies practiced of fresh air, rest, abundant food, and medical and surgical collapse therapy".

Effective Tuberculosis Drugs

It was also around this time that signs began to emerge of the first effective drugs for treating tuberculosis, which would lead to the end of sanatoriums.

In 1944, there was a disputed discovery of streptomycin, according to a book review of The Disputed Discovery of Streptomycin (July 21, 2012), in The Lancet. Two United States scientists, Selman Waksman and a postgraduate research student, Albert Schatz, worked in a scientific program related to soil bacteria at Rutgers University, New Jersey. They discovered that the product secreted by a Streptomyces inhibited the growth of Koch's bacillus and named it streptomycin, reported Expresso.

Without Schatz's knowledge, Waksman had made a deal with Rutgers to receive 20 percent of the net royalties, which in 1948 alone, was $124,000. There was an out-of-court settlement, reported The Evening Bulletin, Philadelphia (October 30, 1952).

And, in 1952, Waksman was awarded the Nobel Prize for the "discovery" of streptomycin, not "development" as there were others involved in the work. Appeals by Schatz and his colleagues were of no avail. "Because of his ill-deserved reputation as a troublemaker, Schatz was never able to find employment as an independent scientist. He died, in 2005, an embittered old man," according to The Lancet book review.

Animal experiments and clinical trials streptomycin of in 1945 and 1946 showed an effectiveness in treating tuberculosis never seen before, according to Expresso.

In Portugal, streptomycin was difficult to obtain as it was sold at a high price and, largely, on the black market. However, Manuel Tapia benefited from political support and supplies from the Red Cross. As early as 1947, Tapia conducted two "remarkable clinical trials", the second of which involved 200 patients, reported Expresso. His conclusions coincided with those of Waksman and Schatz: streptomycin was effective against tuberculosis, and there was no justification for withholding its use from patients who wanted it.

Meanwhile, in 1946, Jorgen Lehmann, a Danish native in Sweden, announced the discovery of para-aminosalicylic acid (PAS) which, although less effective, considerably reduced cases of resistance of Koch's bacillus to streptomycin. The combination of the two drugs resulted in a greater number of cures.

The news about streptomycin spread rapidly in the world. There was an exodus of patients from sanatoriums who opted to be treated at home which intensified after the 1952 discovery of a third anti-tuberculosis drug, isoniazid.

In 1947, the number of patients at Caramulo was 2,059, according to the annual Bulletin. In 1952, the number dropped to 1,636, with a marked decrease in deaths. Of the 20 inpatient units, which were completely full in 1950, only 10 remained in 1970, and these did not have full occupancy. Of the 32 doctors, only 12 remained there. At the same time, the cure rate increased exponentially, and the use of collapse therapy -- pneumothorax and rib-cutting -- fell sharply. In a few years, the hospital was practically empty. Only a few chronic patients and social cases remained behind.

Jerónimo Lacerda's Sons Prepared for the Future

Jerónimo Lacerda's two sons foresaw the end early on. They faced the need to redevelop the vast collection of buildings and equipment.

Abel, who studied Economics, amassed more than 400 works of art, including paintings donated by Picasso and Dali, which were intended for a museum around which he planned to attract visual artists and an arts archive center, reported Expresso. However, in 1957, a tragic car accident at a level crossing took his life when he was only 36.

João (1923-2003), the younger son, had been involved in motorsport at a young age, when he had participated in the Monte Carlo Rally several times. He began collecting vintage cars. Within a few years, he created a museum with rare, high-quality cars, displayed well and all in working order.

Today, the Caramulo Museum, which opened in 1959, showcases the passions of both brothers.

"João Lacerda still tried, unsuccessfully, to negotiate with the Government a future for the Sanatoriums, which would have involved the creation of field hospitals or patient rehabilitation centers. However, the peripheral location of the resort, far from major urban centers, led to the abandonment of any coherent recovery plan. The doctors sought other jobs or retired.

"The sanatoriums had very diverse fates: some were transformed into retirement homes, one was converted into a hotel and two were demolished. But most were left to the elements and are currently in ruins," reported Expresso (March 22, 2023).

TB Since Hippocrates

Tuberculosis had been common since the time of Hippocrates. However, in the 19th century, the slow, chronic course of the disease coupled with occasional flare-ups of the symptoms, made it difficult for physicians to understand its contagious nature, according to Tuberculosis: the sanitarium season in the early 20th century (August 1, 2022), Pathologica, National Library of Medicine.

There was evidence in Italy of sporadic experiments with isolation, at the San Luigi sanatorium in Turin, for example. However, it was Biagio Castaldi, a doctor from Piedmont who first reported on the efficacy of sanatoriums in the Alps for treating patients, claiming that the incidence of tuberculosis dropped at higher altitudes and became much rarer beyond 1000 meters. Before this claim, Herman Brehmer, a German physician, had moved to the Himalayas after becoming ill with tuberculosis. After his recovery, he returned to Germany to found the first sanatorium there.

Conferences on climatology and internal medicine held in Boston (1889) and Berlin (1890) confirmed the importance of sanatoriums, which already were operating by the dozen or under construction in many parts of the world. Isolation, clean air, sunshine and abundant food (6000 calories per day compared to an estimated 3,400 subsistence threshold).

The second half of the 19th century saw a flourishing of sanatoriums in England, Germany, Austria, Hungary, Russia, the Netherlands, Denmark, Norway, Switzerland and the United States.

Davos, with its altitude of 1560 meters, its sunny position, and its dry and airy winters, had one of the greatest concentrations of sanatoriums in Europe. Thomas Mann's The Magic Mountain, set in a tuberculosis sanatorium in the Swiss Alps, was inspired by the writer's time in Davos, where his wife received treatment.

Modernist Style of Architecture

Tuberculosis was "a disease 'without effective medical treatment until the (1940s): until then, architecture was a fundamental part of treatment and prevention."

According to Expresso (March 22, 2023):

"The dominant architecture was inspired by the modernist style of European architects, such as Le Corbusier and Alvar Aalto, who, sensitive to the harmful effects of the unhealthy neighborhoods of large industrial centers, opted to design buildings with straight lines, galleries and vast terraces which facilitated ventilation, reduced contagion and offered ample spaces for restful 'cure'."

Thus emerged a style, Modernism, partially influenced by a disease -- tuberculosis, according to What Tuberculosis Did for Modernism: The Influence of a Curative Environment on Modernist Design and Architecture (October 1, 2005), Medical History, National Library of Medicine. Modernism was a cultural movement which, in architecture and applied design, involved the integration of form with social purpose. It also attempted to create a new classless and hygienic lifestyle with socialist values.

Tuberculosis in Portugal Today

By 2015, Portugal reached the limit of low incidence defined by the World Health Organization, which is 20 per 100,000 cases per inhabitant. In 2022, the incidence rate was 16 per 100,000 cases. Although tuberculosis incidence has decreased by 32 percent since 2015, the mortality rate has remained constant, according to Tuberculosis in Portugal: Intertwining History and Public Health Development (May 6, 2025) World, MDPI.

In Portugal, the burden of tuberculosis remains a significant public health concern, as the Western European country with the highest TB mortality rate of 2.75 per 100,000 inhabitants.