An Examination of the Importance of Agrarian Landscapes and Operations at Virginia Sanatoria Coupled with a Study of the Evolving Role of Nutrition in the Treatment of Tuberculosis at such Institutions

by Margaret Tulloch


I Introduction and Brief History of Tuberculosis

The importance of good nutrition in both preventing and healing illness has long been recognized. Centuries ago, Hippocrates asserted "Let your food be your medicine." While the nature and quantities of foods necessary to ward off illness or cure the afflicted have always been a matter of great debate, proper nutrition, however that may be defined, is of incontestable and universal value. Standards of nutrition have, of course, varied widely according to time and place. For instance, theories regarding the role of diet in the prevention and cure of pulmonary tuberculosis have changed dramatically since the tubercle bacillus was first discovered in 1882 by Robert Koch. As there was no effective biomedical treatment until 1944 when Albert Schatz, working under Selman Waksman, discovered the antibiotic streptomycin through his work with soil samples, nutrition, coupled with rest and fresh air, certainly initially played a more vital role in the treatment of tuberculosis as people "chased the cure" at home or at the early sanatoria. As antibiotics and then chemotherapy supplanted these more homeopathic forms of treatment and the clinical hospital setting replaced the comforts of home and resort-like sanatoria, nutrition began to assume a role of more secondary importance in the treatment of the disease.
The evolution of the role of nutrition in the treatment of the dreaded White Plague, then, was coupled with changes in the settings in which the illness was treated. Prior to the discovery of the tubercle bacillus, consumption, as tuberculosis was then known, was treated primarily in the home, though some consumptives traveled to salubrious climates in places such as the Adirondacks or the Rockies to recover. Consumption in the early 1800s, for instance, was regarded as a wasting disease which produced in its victims a refinement of the body, heightened artistic sensibilities and ennoblement of the soul. At this time, notions regarding diagnosis and treatment varied widely. According to the historian Katherine Ott in her work entitled Fevered Lives: Tuberculosis in American Culture since 1870, "The illness itself was characterized by a fluid group of behaviors, signs, and symptoms, with shifting connotations. Diagnosis depended largely upon a patient's temperament, which could be sanguinous, lymphatic, bilious, or nervous. However, as in other areas of medicine, there was no consensus upon what each signified." Doctors in the 1870s and 1880s offered often conflicting diagnoses and cures, prescribing all manner of "snake oil" patent remedies. One physician even espoused the belief that by wearing a beard, a man could effectively ward off consumption. The Romantic perception of consumptives as the tragically beautiful victims of a wasting disease was replaced with a stigmatized view of "lungers" as the infectious carriers of a devastating illness, as fear of contagion spread in the late 1800s with the emergence of new theories regarding bacteriology.

Towards the turn of the century this escalating terror, coupled with optimism regarding the institutionalized treatments first pioneered at the German "closed institutions" run by Drs. Hermann Brehmer and Peter Detweiler, led to the construction of tuberculosis sanatoria across the United States. According to Sheila M. Rothman, author of Living in the Shadow of Death: Tuberculosis and the Social Experience of Illness in American History, "A generation of physicians, social reformers, and philanthropists were convinced that confining the tubercular in these facilities would promote not only societal well-being by isolation those with the disease but also individual well-being by implementing a therapeutic regimen. The sanatorium satisfied both the drive to coerce and cure." As concepts of bacteriology gained acceptance, the idea of caring for patients in a setting removed from the general populace was considered wise and necessary for preventing the spread of the disease. Not only would such a location ensure the public welfare, but the siting of sanatoria in the countryside was also considered to aid the patients in their recovery. At the time, cities were considered by many to be pestilential and insalubrious places so the notion of patients taking in the fresh air and sunshine of healthful and preferably mountainous, rural settings was persuasive. Even in the early 1800s when notions regarding diagnosis and treatment were far from standardized, fresh air, along with nourishing sustenance, was one of the few antidotes upon which most physicians and patients agreed, especially given society's reluctance to embrace urban life and pandemic fears regarding immigrants, tenements and the physical and moral "evils" of the city. It is not surprising, then, that pastoral settings, often former farms, were viewed as the ideal locations for sanatoria and that many maintained their own agricultural operations, particularly dairies, in order to supply the patients with fresh and healthful alimentation.

Nonetheless as treatments progressed and the responsibility for recovery was subtly shifted away from the patients themselves to their doctors, these sanatoria with their agrarian healing landscapes were closed and converted to geriatric, psychiatric or other such facilities. Their dairy herds were sold at auction, as their fields and pastures were often parcelized and sold for development. According to historian Katherine Ott, today "therapy relies completely upon chemotherapy. There is no need for a change in lifestyle, personal habit or mental adjustment." Tuberculosis today is treated in clinical, modern settings where efficiency and technology are of primary importance and the mantra of "fresh air, rest and good food" is accepted as intuitively, rather programmatically, important. The outpatient clinics and hospitals of today are often found in urban settings, as tuberculosis has increasingly become a disease of AIDS patients and the homeless - ironically, the very settings which in the early part of this century were believed to cause the disease. As Ott astutely observes, "The history of tuberculosis chronicles how a romantic, ambiguous affliction became first a dreaded and mighty social truncheon, and finally an entity bound up in the public health and civic order." Thus, the evolution of medical and popular notions regarding tuberculosis is reflected in the changes of the settings in which the disease was treated, ranging from the early sanatoria with their pastoral healing landscapes and agricultural operations to the more antiseptic and clinical, from both a physical and metaphorical standpoint, modern hospitals of today.

It is in this larger context that the history of tuberculosis sanatoria in Virginia unfolds and is best understood. Blue Ridge Sanatorium, for instance, is representative of many of the early sanatoria in Virginia and beautifully embodies this complex evolution of theories regarding tuberculosis. By examining its current physical form and looking back through its archives to see how the site has changed over time, as well as by researching the institution's shifting attitudes toward the treatment of tuberculosis and resultant transformations in the way of life at Blue Ridge, we can begin to comprehend this history. As we have seen, agriculture and nutrition played an important interrelated role in the treatment of tuberculosis at such institutions and it is through this particular lens that we will regard the history of the disease at Virginia sanatoria such as Blue Ridge Sanatorium.


II Blue Ridge Sanatorium as a Representative Example of Early 20th Century Sanatorium Design

The architecture and landscaping of Blue Ridge Sanatorium, founded in 1919 by the Commonwealth of Virginia for the treatment of white tuberculosis patients, is in several respects typical of many sanatoria built after the turn of the century, reflecting medical and popular notions regarding the nature and treatment of tuberculosis. For instance, Blue Ridge Sanatorium almost perfectly exemplifies the recommendations regarding the construction of sanatoria espoused in Tuberculosis Hospital and Sanatorium Construction, a manual written in 1911 by Dr. Thomas Spees Carrington. This text can be seen as representative of the cutting edge ideas of the day regarding the construction of tuberculosis sanatoria. An overview of Blue Ridge Sanatorium demonstrating how it embodies Carrington's recommendations will serve not only as a brief introduction to the site itself, but also as evidence that Blue Ridge can indeed be viewed as representative of the most advanced early 20th century theories regarding the treatment of tuberculosis and a fine example of American sanatorium design, incorporating both architecture and landscaping into a unified whole for the purpose of treating the White Plague.
For instance, Carrington asserts in his treatise that sanatoria should be located a short distance from a town or city. Blue Ridge is located but a mile or so from downtown Charlottesville, Virginia, close enough to ensure easy access for visitors, yet far enough away so as to reduce fears of spreading the disease. Carrington also suggests that sanatoria are best constructed near transportation facilities, such as railroads or trolleys. Blue Ridge is linked to the local train station by one mile of macadamized road. Carrington next recommends that the ideal site for a sanatorium should be "a tract of land from twenty to two hundred acres in extent and it will be more valuable for its purpose if it includes forest, orchard and land that can be cultivated." Though he adds that any site can be greatly improved through careful landscaping, he goes on to suggest that a tract with rolling hills, mountains or meadows is preferable as its natural beauty may help to reduce the high number of "walk-aways" with which most sanatoria had to contend. Blue Ridge, of course, is located on a lovely hilly site of perhaps 100 acres surrounded by the Blue Ridge Mountains with wooded areas, an apple orchard, vegetable gardens, cow pastures, fields of corn and hay and meticulously landscaped grounds - all that Carrington recommends and on one site no less.
Though Carrington does not elaborate in great detail the thinking behind his recommendations, it is clear that he was at the vanguard of sanatorium design based on current theories regarding the treatment of tuberculosis and that Blue Ridge Sanatorium embodied such ideas. For instance, undoubtedly ascribing to the notion that fresh air, particularly at high elevations, could speed an invalid's recovery, Carrington suggests that the meteorological conditions of a prospective site be evaluated and that southern exposure on a hill or mountain is preferred. Blue Ridge Sanatorium was constructed on just such a site. Also, though he does not elaborate exactly why grounds ought to be "artificially improved," on some level Carrington and the designers of the sanatorium must have realized the uplifting and healing effects of good landscape and garden design. Though Blue Ridge Sanatorium enforced the rule that individuals were "'to keep off the grass, and not to break flowers or shrubs on the grounds,'" the immaculately landscaped lawns, carefully clipped boxwood hedges and stunning mountain views which former patients and physicians remember surely had a restorative and palliative effect on patients and staff alike. As recent studies have shown, "Perhaps having gardens and views - and all they imply - during the earliest phases of hospitalization and throughout the entire recovery, might well reduce this loss of connection [to the external world] and enhance healing and recovery." Margaret Rastetter, a patient who "chased the cure" at Blue Ridge for eight months in 1941, recalled that the grounds at Blue Ridge were a place for contemplation for all and long walks for the stronger patients. Sanatorium designers, such as Carrington and those who planned Blue Ridge Sanatorium, undoubtedly had such images in their mind's eye when determining the setting and landscaping for their hospitals.

While Carrington thus carefully describes the ideal setting for a sanatorium, he also goes on to discuss the structures one may find on a prospective site, their potential for adaptive reuse and the types of new structures which ought to be constructed to complete a sanatorium campus. For instance, Carrington notes that "often farm-houses or other structures stand on the land chosen and can be remodeled so as to make useful sanatorium buildings … An old country mansion will often make a good administration centre …" Blue Ridge Sanatorium was indeed originally the site of a large farm owned by the Lyman family, the centerpiece of which was the family's stately c. 1870s Victorian house. This mansion was transformed into the administration building of the sanatorium for many years, much as Carrington suggests. In addition to advocating the reuse of existing structures, Carrington also describes the other types of buildings which should be constructed as part of a sanatorium, including free-standing brick power houses, hog enclosures, silos and the like, all of which can be found nearly exactly as he describes them at the Blue Ridge site.

As for staff buildings, Carrington recommends that they be "hygienic and sanitary with provisions for outdoor sleeping," as many staff members would be current or former tuberculosis sufferers and would surely benefit from housing with good ventilation. The solid foursquare colonials designed by Eugene Bradbury for the more senior physicians residing at Blue Ridge, with their sleeping porches and large windows, epitomized such thinking regarding the treatment of tuberculosis at this time. Many of the physicians at Blue Ridge, such as Dr. Kenneth Heatwole, did indeed begin their careers at the sanatorium as patients. The houses in which they were assigned to live, like the patient quarters, were distinguished from contemporary domestic and institutional architecture primarily by the presence of sleeping or cure porches, similar though related architectural elements designed to facilitate the fresh air cure. Introduced to and popularized in the United States by Drs. Edward Livingston Trudeau and Alfred Loomis at their pioneer sanatorium in the Adirondacks, the Outdoor Life, a regimen of fresh air, rest, and nourishing food, was considered the height of treatment for pulmonary tuberculosis in pre-antibiotic America. Sleeping or cure porches were seen as an integral part of the cure process as they allowed patients to be "out of doors" preferably day and night, while being somewhat protected from the elements. Patient Margaret Rastetter recalled, "barring inclement weather such as a hurricane or a blizzard, we were on that porch." Carrington, surely mindful of this cure regimen characterized by mountain air, plenty of rest and farm fresh food, appears to have tried to incorporate such theories into his recommendations on sanatorium design. Blue Ridge, as it exemplified such ideas, thus was in many respects not only a typical, but a model sanatorium. Therefore, Blue Ridge Sanatorium will serve, accompanied by references to sanatoria in other areas of the Commonwealth, as an excellent study model for a more detailed examination of the interrelated role of agriculture and nutrition in the treatment of tuberculosis at Virginia sanatoria, with perhaps wider implications for the study of tuberculosis at sanatoria constructed across America at this time.

III Blue Ridge Sanatorium as a Pastoral and Agrarian Site

From its agrarian past to its impressive dairy operations down to its pastoral landscaping, the Blue Ridge site has until very recently exhibited a strong connection to agriculture. Such a strong affiliation is not due to mere happenstance. Rather, it is to some extent the result of popular and medical notions regarding the salubriousness and healing powers of such landscapes and, of course, to the real and perceived importance of supplying tuberculosis patients with ample quantities of high quality food as part of their treatment regimen.

Originally the area which came to be known as "Sputum Hill" was the site of agrarian operations, ranging from rudimentary to sophisticated, dating back to 1730 when John Carter, Secretary of the Colony and eldest son of Robert "King" Carter, received a Crown grant of 9,350 acres, encompassing the area still referred to today as Carter's Mountain. John Carter established two mills on his property, one on the west side of the mountain near the north fork of the Hardware River and the other on the east side. In 1742 John Carter died, bequeathing this land to his son Edward. According to the 1782 state property tax assessment, Edward Carter was by far the wealthiest individual in Albemarle County, as he possessed 237 slaves, 198 head of cattle and 62 horses, mules and colts, certainly indicating the presence of farming operations. Thomas Jefferson, a gentleman farmer who idealized the agrarian way of life and upheld the importance of yeoman farmers, had only 129 slaves, 106 head of cattle and 23 horses. At Edward Carter's death, this land was conveyed to William Champe Carter who then transferred 400 acres surrounding Moore's Creek to his brother, Edward H. Carter. Then in 1801, Edward H. Carter sold 372 acres of this land to Benjamin Brown. Under Benjamin Brown's ownership the property, now referred to as a plantation, came to be known as Mooresbrook, a name which was later given to Moore's Brook Sanatorium, the sanatorium which predated Blue Ridge Sanatorium. In 1812, Benjamin Brown and his wife sold 312 acres to Robert B. Streshly for $4,368. Farming was certainly well under way on the land by this time, as Thomas Jefferson's account books indicate that he bought corn from Robert Streshly in 1813. Over the next few decades, the property changed hands several more times and the lands used for agricultural purposes were expanded to include extensive cropland and pastureland for livestock.

Then in 1903 the current owners of the estate, Jane-Ellen Lyman and Henry L. Lyman, sold 106 acres to Moore's Brook Sanatorium Company, Incorporated. At the time, the property was a large, successful farm, the centerpiece of which was a fine c. 1870s Victorian house with intricate woodwork and a spiral staircase. Interestingly enough, Mrs. Lyman and her son reportedly both suffered from tuberculosis, a fact which undoubtedly influenced Henry Lyman to eventually become a doctor and found his own tuberculosis sanatorium in New England. Nonetheless, the Moore's Brook Sanatorium was not specifically a tuberculosis sanatorium. Rather, it was a privately run institution specializing in the treatment of mental and nervous disorders, as well as alcohol and drug addictions, according to a 1904 advertisement for the sanatorium. The advertisement describes Moore's Brook Sanatorium as:

An easily accessible but secluded home for the private treatment of mental and nervous diseases, alcohol and drug habitués -- A splendid old Colonial place, over 100 acres, mature in grove, grass and vine; new only in equipment. Buildings brick, with brick partitions; 250 feet of wide veranda; new lighting plant; new hot water heating plant; beside open fireplaces in nearly every room. Billiards, pool, golf, tennis, etc.. Committed or voluntary patients received. Home one mile from station; macadamized road; long distance 'phone 149. Carriages meet all trains on call.

The land, after a long and complex history of changing hands, thus began its transformation from the site of extensive privately-owned agricultural estates to privately and subsequently publicly run health care institutions. Nonetheless, a connection to agrarian, or at least pastoral, landscapes was maintained to varying degrees throughout the institutional history of the site.

A 1913 advertisement for Moore's Brook Sanatorium, for instance, indicates the presence of dairy cows, egg hens, fruit orchards, vegetable gardens and a stable as selling points for its institution. It reads:
A mountain resort for both sexes for the treatment of Mental and Nervous Diseases, Alcohol and Drug Habitues. One mile from trunk lines of Southern and C&O roads. A splendid old colonial place. 250 feet of wide veranda. Best steel frame fly screens throughout. Gas and electric lights. Hot water heat. Pure Holstein milk, eggs, fruits and vegetables raised on the place, always fresh and abundant. Strictly up to date treatment. Clientele of the best. No epileptics taken. Resident Physician had eleven years' experience in Alienistic work in some of the best hospitals North and West before establishing Moore's Brook in 1903. Billiards, Pool and out-door amusements. Patients keeping automobiles or vehicles given free storage. Horses cared for at prevailing livery rates.

The Moore's Brook Sanatorium Company, however, was dissolved a year later and its land sold to Dr. and Mrs. David M. Trice. In 1919 Mrs. Trice, who had become sole owner of the property upon her husband's demise, sold the 106.2 acre tract to the Commonwealth of Virginia for $32,000 cash. The Commonwealth decided that the foot of Carter's Mountain would be an ideal location for the creation of the Blue Ridge Sanatorium, undoubtedly for its location close to yet removed from Charlottesville and the availability of expert medical care at the nearby University of Virginia Hospital, not to mention the fact that the site in so many respects perfectly matched the sanatorium site paradigm described in treatises such as Dr. Carrington's aforementioned Tuberculosis Hospital and Sanatorium Construction. Furthermore, the City of Charlottesville offered to contribute $15,000 towards its construction and guaranteed free water from the City for a period of five years. Nonetheless, the importance of the salubrious rural setting, with its breathtaking views of the Blue Ridge Mountains, and the presence of existing farm operations which could be used to provide fresh food for the patients should not be underestimated, as such factors certainly played a role in determining the location of the sanatorium.

Undoubtedly both consciously and unconsciously recognizing the natural advantages of such a site, the administrators of the new Blue Ridge Sanatorium carefully maintained a connection to the land as the sanatorium grew in size and scale over time. That is, even as the institution expanded and more and more buildings were constructed, the site retained something of its former pastoral and rural heritage. According to Catherine Everly's history written to commemorate the 50th anniversary of the Blue Ridge Sanatorium, "at the time the Sanatorium was opened in 1920 there were four buildings on the grounds. Since then Staff Houses, Maintenance Shop, Heat Plant, Sewage Treatment Plant, a 200,000 gallon water tank … have been added. Today there are 40-50 buildings." Thirty one years after Everly wrote this and many changes to the site later, there still exists a restful, pastoral feeling at this hilly site with its wide open, sloping lawns and vistas of the Blue Ridge Mountains, even though the agricultural lands have been sold off and the farm complex has been abandoned and divorced from the main campus. The many individuals from Virginia farming families admitted as patients must certainly have taken comfort in the rural setting of the sanatorium and its pastoral landscapes.

This is not to say, however, that the sanatorium had a purely agrarian appearance. Rather, the site was landscaped and beautified through the planting of specimen trees and the careful clipping of hedges. For example, in 1925 the lawns were considerably enlarged and an impressive number of shrubs and flowers were planted, adding to the appearance of the grounds. In 1952, the Minutes of the 88th Board Meeting of the State Board of Health Committee for Blue Ridge Sanatorium describe the grading and terracing of certain areas of the site and mention the planting of trees, shrubbery and flowers. Such efforts were not lost on doctors and patients. Dr. and Mrs. Heatwole, for instance, fondly remembered the meticulously landscaped lawns dotted with maples, mimosas, hollies and firs. They also recalled that boxwood hedges planted in the 1920s surrounded the superintendent's house where they resided for several years and could be found near other buildings on the site. Patients, such as Margaret Rastettter, reminisced about the colorful flower beds which the patients could gaze down upon from their sleeping porches long after they left the sanatorium. Nonetheless, while the site was thus "artificially improved" through careful landscaping, it certainly retains some of the romanticism of rural life in its expansive field-like lawns and the gentle curve of its paths, both of which are diametrically opposed to the confined spaces and grid-like street networks of "unwholesome" inner cities.

The bucolic feeling at Blue Ridge Sanatorium would certainly have been much stronger during the early days of its history. For instance, the Heatwoles recalled apple orchards, vegetable gardens, cow pastures and fields of corn and hay located on the site. Mrs. Heatwole added that hogs were raised in the woods behind the Davis Building. Indeed, Blue Ridge Sanatorium postcards, a popular way for patients to keep in touch with family and friends during the isolation of their stay at the sanatorium, reveal a close physical proximity between the grounds and the agrarian fields and pastures. For instance, one postcard depicts haystacks and cultivated fields directly behind the superintendent's house and another portrays cows grazing behind the Wright Building. Over time, however, the separation between the pastoral and agricultural landscapes widened. The dairy barn originally located on the site of the Activities Building was relocated and a new barn complex constructed in 1939 out of view of the main campus. Likewise, the vegetable gardens which used to supply the patients with fresh vegetables were abandoned around this same time in the 1930s. Thus, the agricultural operations which originally were in close proximity to the main grounds were pushed further away undoubtedly as the result of changing perceptions of how a health care institution should look.

Even as the Blue Ridge Sanatorium pushed the agricultural operations to the periphery of its property, the institution nonetheless recognized the value of its rural setting, acquiring small tracts of land now and then over the years not only to expand the pastureland available for its growing dairy herd, but also to protect nearby land from development. For instance, in 1932 the sanatorium purchased 111.8 acres abutting the sanatorium's property in order to expand its dairy operations. Similarly, in 1937 Governor George C. Peery approved funding for Blue Ridge to purchase fifty acres of grazing land "in order that the milk supply produced by the Sanatorium herd may be increased," instead of renting one hundred acres of adjoining pastureland for $25 a month. Likewise, on July 1, 1946, the sanatorium purchased from the Virginia Association of Workers for the Blind the ninety-four acre Brookdale Farm located across Scottsville Road for a price of $40,000. Included in this price was a herd of twenty-nine Holsteins, a team of horses, some farm machinery, a "dwellinghouse" and two tenant houses, as well as dairy, horse and calf barns. According to the Minutes of the 81st Meeting of the State Board of Health Committee for Blue Ridge Sanatorium held on May 20, 1947, this acquisition provided the sanatorium with the "additional land which has been needed for some time necessary to maintain the two dairy herds that will supply the Sanatorium with the amount of milk needed for the institution." A second motivation for purchasing this land, however, was to protect the rural character of the area surrounding the sanatorium. "To let this property fall into the hands of Real Estate dealers would mean it might be sub-divided into small homesteads, and we would have, right at our front door, undesirable neighbors," counseled Frank Stafford at the 80th Meeting of the State Board of Health Committee held on May 14, 1946. These are but a few representative examples of the types of land acquisitions made throughout the years.

Though this land created an additional buffer around the sanatorium, protecting it from encroaching development, little could be done when the Commonwealth announced the construction of Interstate 64. In 1955 the Department of Highways requested the transfer of a small strip of land from Blue Ridge Sanatorium for widening and improving the intersection of Routes 53 and 20. The impact of this project, however, was minimal and in no way prepared the sanatorium for what was to come with the construction of Interstate 64. That is, this thruway divided the sanatorium's pastureland to the extent that it appeared inadvisable to continue farm operations. According to the 1968 Annual Report to the State Health Commissioner, "With the construction of Interstate 64 which has taken much of the farmland, access to the barns and certain pasture lands is almost impossible. Because of this, it was recommended that farm operations be discontinued as of June 30th, 1968, and milk be bought from the local dairy. All livestock was disposed of prior to June 30th." Thus, as the agricultural operations became isolated from the main campus and eventually discontinued altogether, the divisions between the constructed nature of the landscaped grounds, the tilled fields and maintained pastures associated with the institution's agricultural operations and the untamed nature beyond were more clearly drawn than ever before.

While the pastoral landscapes were prized for their restorative healing properties, the agricultural fields and pastures were valued above all for the nourishing foods which they produced. Proper nutrition, in addition to fresh country air and good rest, was one of the most important elements of the cure regimen before and, to a lesser extent, after the advent of antibiotics. The dairy operations, for instance, were started in 1925 in order to supply patients with the fresh milk which they were required to imbibe several times a day. According to a 1937 letter written by Superintendent and Medical Director Dr. W.E. Brown to State Health Commissioner Dr. I.C. Riggin, "As you probably know we have always experienced difficulty in getting a sufficient quantity of good milk at reasonable prices on this market. This condition forced us in 1925 to start a small dairy of our own." He continued, "Good milk being an essential part of the diet in the treatment of tuberculosis, it is necessary that the Sanatorium have a large quantity of this food, and that it should be of the highest quality." The herd began with twelve registered Jersey and Guernsey heifers, selected because their milk had a higher butterfat content than the Holstein milk sold by the local dairies, specifically Monticello Dairy, from which the sanatorium purchased milk. There were several dairies in town, however the constant demand for milk at the sanatorium was evidently difficult to satisfy at a low price. The 1927 edition of Hill's Classified Directory of Charlottesville lists under the heading of dairies Hunter J. Crenshaw on Monticello Road near Moore's Creek, Davis R. Bruce on Park Extended near Watson Avenue, Monticello Dairy at 405-409 East Water Street and William H. Smith at Locust Avenue Extended. And so, existing barns were renovated at a small cost and the first milk cows were purchased in 1925.

The sanatorium dairy was deemed a huge success both in terms of the healthful milk produced and the financial savings realized. According to a letter dated August 18, 1937 from Dr. I.C. Riggin, State Health Commissioner, to Governor George C. Peery "The consumption of sweet milk at Blue Ridge Sanatorium averages 130 gallons a day - an average of 100 gallons produced on the sanatorium farm and the balance purchased from other sources. It is estimated that milk is produced on the farm for about 20 cents a gallon, whereas milk of the same quality purchased on the outside costs between 28 and 35 cents a gallon." The herd was expanded greatly over time and, as we have already seen, the sanatorium purchased additional pasturage on several occasions. Blue Ridge was justly proud of its herd. For example, the 1933 Annual Report reads "We feel especially proud of our herd, and in the past year it led all herds in Albemarle County who were in the Cow Testing Association in butterfat production, and was third in milk production. Many large herds of pure bred Holsteins were included in this Association testing, and only two of them exceeded our Jersey herd in average quantity of milk per cow." By 1937 the herd consisted of 40 registered Jersey cows and 12 registered Jersey heifers, all of which were raised on the Blue Ridge farm.

As the patient population increased and milk needs rose, it was deemed necessary in 1939 to build a new farm complex at some distance from the main campus. The old bank barn which had been used as a dairy and horse barn was transformed into a new heating plant and "a site was selected out of sight of the Sanatorium, a distance of about one-quarter mile, for the location of the farm buildings," according to the minutes of the 72nd Board Meeting of the State Board of Health Committee held on May 23, 1939. The selection of such a site removed from the main campus coincides with the initial distancing of the sanatorium from the "rest, fresh air and good food" cure.

Nevertheless, certainly an indication of the importance of the institution's dairy operations, the same architect who designed the East Wing of the Main Building, W. E. Stainbeck, was selected to design the new farm complex which included a large cow barn, a stable, a milk house and two silos. These impressive farm buildings incorporated the most up-to-date design features of the day, including feed and litter carrier tracks. The concrete floors could be easily washed down and disinfected. Heifers were carefully separated from calves and bulls and all were given adequate stall space. In their efficiency, orderliness and modernity, these farm buildings are similar to the patient building also designed by Stainbeck. The East Wing, after all, is cleanly designed and efficient with little ornamentation and easy to clean linoleum floors. Male and female patients were relegated to different sides of the building so as to prevent unseemly intermingling. Thus, there are distinct similarities between Stainbeck's design for the farm complex and for the new patient wing. Nonetheless, the bracketed overhanging eaves, the white clapboard siding and gambrel roof design of the barns were all drawn from traditional barn designs and were in keeping with the idealization of agrarian life at the institution. Indeed, similar architectural details could be found on the three original forty-bed patient pavilions, Thomas, Addison and Strode, which were constructed in the 1920s and demolished by 1951. Thus, both the modern and traditional elements of the barns, which recall the designs of various patient buildings, once again express the close historical connection between the main campus and the agricultural operations at Blue Ridge Sanatorium.

Originally some proposed that patients might perform some of the agricultural work on the farm as their conditions improved. After all, it was thought that carefully monitored outdoor exercise could hasten a patient's recovery. Nonetheless, this idea was never embraced at Blue Ridge and farmhands were hired to take care of the fields and the dairying. In the 1950s, professional advice on farm management practices was given by John A. Smat, head of the Thomas Jefferson section of the U.S. Soil Conservation Service. According to a letter written in 1951 by Frank Stafford, Superintendent and Medical Director of Blue Ridge Sanatorium, "we have living next to the Sanatorium farm a man who gives us much information on farm management, crop rotation, suitable seeds, etc.." Day-to-day decisions regarding the farm, however, were made by the farm foreman who reported to the sanatorium administration.

One of the most challenging ongoing problems facing the farm foreman and the sanatorium administration was the retention of experienced farm laborers. In January 1955, two farm cottages were constructed with the idea that providing adequate housing near the site would encourage workers to stay. According to the minutes of the 92nd Board Meeting of the State Board of Health Committee on May 19, 1955, the sanatorium "completed two farm cottages - one for the Farm Foreman, and one for a worker in the dairy (his wife also works in the culinary department)." Interestingly enough, these cottages were constructed for $3,500 from materials salvaged from the demolition of the two original patient pavilions, again illustrating the close tie between the main campus and the agricultural operations.

During World War I and World War II, the labor shortage was so acute that prisoners took over many of the duties on the farm and in the culinary department. Prisoners had, after all, been housed on sanatorium property near the maintenance buildings since the early days of the sanatorium, perhaps yet another indication of the fear and loathing with which tuberculosis patients were regarded by the public and the state. In 1943, Dr. W. E. Brown, Superintendent and Medical Director at Blue Ridge Sanatorium, requested that a group of trusty prisoners, or "trusties," be allowed to help the hired staff with their duties. By the next year, four prisoners were working on the farm, fourteen were in the culinary department and three helped to maintain the buildings and grounds. The so-called prisoner Honor Camp enabled the sanatorium to remain solvent during this difficult time period. Writing to Governor Darden, Brown noted "We are dependent upon our dairy herd to supply us with milk, and if we lose any more men on the farm, we will be unable to properly milk the herd. Milk cows can be easily ruined when they are in heavy production if they are not milked regularly … If we lost any more from our kitchen and dining room help I do not see how we will be able to serve meals at the institution." Nonetheless, with the help of the Honor Camp, the institution was able to stay open during such lean times.

With this labor shortage resourcefully remedied, the only major setback in the history of the dairy operations, other than the construction of Interstate 64 in 1968 which cut through prime pastureland, was a 1947 outbreak of Bang's Disease. Traced back to an open wound on the shoulder of one of the farm's horses, this disease ravaged the herd. 59 cows, 2 heifers and 3 horses were destroyed. The cattle were sold as "canners" for $5,592.14 and the Commonwealth issued an indemnity for 43 cows worth $1,290. Nonetheless, the sanatorium administration was very distressed over the loss of its prize Jersey herd. The patients, too, must have been heartbroken to learn that the cows, long the source of one of the key elements of their treatment regimen, had been stricken with a disease as devastating as the tuberculosis which they battled.

Fortunately, that same year, the institution had acquired the nearby Brookdale Farm and its Holstein herd. By the end of the year then, having purchased 38 new milk cows and one bull, the institution was able to produce more than 150 gallons a day from the two herds, thereby meeting its milk needs. The total herd on the two farms numbered 120 head of cattle, including 74 cows, 43 heifers and calves and three bulls. This was indeed an impressive dairy operation.

Though the institution had been pasteurizing its milk since 1931 in order to curtail attacks of diarrhea due to Undulant Fever, Blue Ridge went so far as to construct a specialized pasteurization and bottling plant in 1954. The plans were drawn up by the Engineering Section of the Governor's Office and executed by Culpepper Building and Supply Corporation, the low bidder for the project. According to the minutes of the 88th Meeting of the State Board of Health Committee held on May 15, 1952, "The Pasteurization and Bottling Plant has added a great deal to the handling and serving of milk, and makes for a more uniform distribution of the cream content. This was a project which should have been constructed quite some time ago." Indeed, the dairy eventually became so successful that it was able to sell surplus milk to local dairies. For instance, the 1960 Annual Report indicates, "During the fiscal year we produced and pasteurized 54,820.5 gallons of milk. Of this amount the Sanatorium consumed: 33,316.5 gallons of bottled milk (.75 per gallon - total $24,987.38), 15,724 gallons of bulk milk (.65 per gallon - total $10,220.60). Of the amount of milk produced, the Sanatorium sold for butterfat to the local dairy 5,780 gallons, and received $993.90." The dairy was thus a wonderful asset for the sanatorium for both treatment regimen and financial purposes. However, by the time the Interstate cut through the pasturelands in 1968, streptomycin had replaced the earlier "fresh air, rest and nourishing food" cure of earlier days and so it was easier to make the decision to terminate dairy operations than it previously would have been. The history of the Blue Ridge Sanatorium thus cannot be fully understood without recognizing the actual and symbolic importance of both its pastoral landscapes and agricultural operations.

The dairy operations were certainly the focus of the agricultural endeavors at Blue Ridge, to the extent that in later annual reports it is evident that nearly all other agricultural operations at the institution were intended to support the herd. For instance, the 1960 Annual Report reads, "As in previous years, the farm has not been used for trucking purposes, but has been utilized for grass, making hay and producing food in order to produce milk for sanatorium needs." Hay and ensilage corn were the two most important crops at the sanatorium during these years. Nonetheless, hogs, in addition to the prizewinning Jerseys and Holsteins, were raised at the sanatorium. Originally the hogs were raised loose in the woods primarily to consume garbage, though some were sold on the open market for a profit. In 1954, the Farm Coordinator recommended, as the hog sales contributed a fair amount of revenue to the sanatorium, that the institution's hog raising practices be modernized. He suggested constructing farrowing pens and separating the pigs from the older hogs in order to better fatten the younger animals. During the lean times of World War I, the Great Depression and World War II, however, some of the hogs were gratefully consumed by sanatorium patients. According to the 82nd Meeting of the State Board of Health Committee on May 18, 1948, "Since the early days of the Sanatorium, we have produced hogs from our refuse, largely from the culinary department. During the latter part of the war, and the years that have followed this when there has been a shortage, we were unable to get good quality meat in the necessary amount for our patients. In the attempt to relieve some of this shortage, we have given more attention to the raising of hogs." The administration determined that by feeding surplus corn to the hogs four to six weeks prior to butchering, the meat would harden and be of a superior grade. This same 1948 report indicated that there were 150 hogs and pigs at Blue Ridge Sanatorium and that over the past 18 months the abattoir in Charlottesville had butchered and processed 31 hogs representing 8,364 pounds of meat for use at the sanatorium as pork, sausage and lard. During that same period, 19 old sows and boars of inferior quality, weighing approximately 8,670 pounds were butchered and sold for $1,288.64. The agricultural operations at the sanatorium thus included much more than just the impressive dairy.

From the rural setting of the sanatorium to its pastoral landscaping and extensive farm operations, it is clear that agrarian themes feature prominently in the Blue Ridge site and experience. Ideally suited for the rest and fresh air components of the cure regimen, this site provided a peaceful and healthful setting for the patients. The administration, perhaps recognizing this consciously or subconsciously, landscaped the rural site in a pastoral manner, thereby enhancing the healing properties of the natural environment. The dairy, of course, provided the fresh milk which represented another essential part of the cure regimen. Thus, both the natural and worked landscape provided patients with the essentials for the "rest, fresh air and good food" regimen which dominated the treatment of tuberculosis in the early years of the sanatorium and supplemented the surgical and antibiotic treatments administered in later years.


IV A Brief Comparison with Piedmont Sanatorium in Terms of Site Characteristics and Landscaping Design

Like Blue Ridge Sanatorium, other sanatoria in the Commonwealth of Virginia sought out rural sites and created pastoral landscapes for the benefit of their patients. Furthermore, farm operations were so prevalent at health care institution sites throughout the Virginia that in 1950 the Commonwealth conducted an Institutional Farm Study to ascertain the types and quantities of foods produced at such institutions with the objective of coordinating food production and facilitating produce exchanges between the institutions. Both public and private sanatoria had farms and dairies associated with their facilities. Dr. Henry Gilmore Carter, Superintendent of Piedmont Sanatorium in Burkeville, wrote of Blue Ridge, Piedmont and Catawba Sanatoriums, "The three institutions are operated under the same general management; and treatment, etc., is as nearly uniform as it is possible to make at three separate institutions." Of course this is not entirely true given the differences in the ways in which, for instance, the white patients at Blue Ridge were treated compared to their African-American counterparts at Piedmont Sanatorium. For instance, the funds allocated to Blue Ridge for the fiscal year 1951-1952 were $709,126.11 as compared to $522,024.15 for Piedmont. Nonetheless, in terms of site selection and design, there are some important similarities between the two sites. Significantly, Piedmont Sanatorium was established in 1918 on a 310 acre farm site located approximately one mile outside of Burkeville, just as Blue Ridge was situated on a former farm a mile or so from downtown Charlottesville. This site was selected for many of the same reasons that the Blue Ridge site was chosen. That is, "This site was chosen because of accessibility, labor, climate and transportation facilities, there being two railroads - Southern and Norfolk and Western - passing through Burkeville and a main highway from Danville to Richmond all bordered the property chosen. Also, the majority of the Negro population of Virginia was to be found in this, the south-eastern or Piedmont section of Virginia," according to a history of Piedmont by Ethel C. Dodson who worked there in one capacity or another from 1920 to 1968. Nonetheless, the salubriousness of the rural setting and the natural advantages of having farming operations already in place were surely considered positive attributes of the site.

After all, Ethel Dodson noted "There was already a small dwelling and dairy barn on the land and a garden was started, cattle bought to start a dairy in order that there would be fresh vegetables and plenty of milk available for the patients when the buildings were completed and the patients admitted." According to a 1921 site plan, there was a large stable, a wagon shed, a hen house and several sheds and other barn structures. Today, there is an impressive open pole barn used for storing farming equipment, a large silo and two concrete block buildings which were most likely used in dairying operations. In addition, two simply designed white clapboard farm workers' houses are situated on Maple Road near the farm complex. Thus, both Blue Ridge and Piedmont were rurally located with extensive agricultural operations.
Nonetheless, the sites differ both in terms of their natural characteristics and landscaped features. While Blue Ridge is a hilly site with stunning views of the Blue Ridge Mountains, Piedmont is located on a relatively flat site which stretches out from the main campus to the surrounding cultivated fields. Whereas a spring behind the Davis Building supplies Blue Ridge with fresh water, the Piedmont site encompasses two substantial ponds which animate the site, one near the barn complex and another to the west of the main buildings. One of the most significant differences between the two sites, however, is the difference in landscaping. As previously mentioned, Blue Ridge Sanatorium has a pastoral feeling with field-like expanses of turf dotted with specimen trees and occasional clipped hedges and flowerbeds. By contrast, the main campus at Piedmont is dominated by grand native pine trees through which patients could look out onto the flat fields used for raising crops and a dairy herd. According to Piedmont's records, in 1921 a flock of goats was introduced to clear the underbrush from around the pine trees. This was not, however, the extent of landscaping efforts at Piedmont. For instance, in 1923, the Superintendent was "instructed to look into the question of planting some pecan trees with a view to beautifying the grounds and as a possible financial investment." Again, later that year, it was reported that "the grounds around the Sanatorium proper have been laid off into plots with mounds of flowers, hedges, etc. The garden in front of the Women's Buildings has been carefully groomed and paths provided in order to save the grass. Mr. Wm. N. Roper, Manager of the Arrowfield Nurseries of Petersburg was kind enough to donate 100 comma bulbs all of which have been planted." Nonetheless, despite such landscaping efforts, the pine trees are unmistakably the dominant feature of the main campus at Piedmont. There is a sharp delineation between the pine forest of the patient's space and the wide open agricultural spaces. This landscape differs greatly from the pastoral lawns at Blue Ridge which, in the institution's heyday, seemed to flow into the surrounding agrarian lands. Rather, the lawns and fields at Blue Ridge were united in form and separated only by fencing. Thus, at Piedmont with the dramatic distinction between two very different landscapes, there was somehow less of the pastoral ambiance found at Blue Ridge, despite the presence of nearby agricultural spaces. Nonetheless, both sites benefited from the purported healing properties of rural settings, fresh air and pastoral landscapes.


V Nutrition as Part of the Cure

Nevertheless, one of the most important practical advantages of having farm operations at these sanatoria was that they could be used to furnish patients with abundant quantities of wholesome food. Proper nutrition, after all, was thought to be of central importance to the cure regimen. According to a February 1921 article in Sunbeams, a monthly published by Catawba Sanatorium which was devoted to the interests of tuberculosis patients, "The stomach of the tuberculous patient is his best friend." Before the introduction of streptomycin, the cure consisted primarily of fresh air, rest and good food. A May 1923 Sunbeams article entitled "The Cure," explains that nourishing food "furnishes the material with which to replace tissue destroyed in the conflict with the disease." Nonetheless, theories regarding the quantities and types of food to be consumed varied greatly over time. For example, in 1925, a report by the Blue Ridge Sanatorium Superintendent indicates that the value of animal protein was reevaluated. "Believing that our patients were consuming too much animal protein in the form of meats, we have changed the menus so that at present our beef consumption is only about half what it was at this period last year. We have increased the fruit and vegetable diet and the consumption of milk. This change has been accomplished without any serious complaints from the patient body," reads the report. The Blue Ridge medical staff thus continually evaluated and altered the patients' diet.

Nonetheless, over the course of the sanatorium's history, some changes in diet were due to external circumstances, not simply to internal programmatic goals. For example, during World War I, the Great Depression and World War II, it was difficult to obtain ideal food rations for the patients. As we have seen, while hogs raised in the woods were historically thought to be unfit for patient consumption, during the lean wartime years they were eagerly consumed. Even after the end of World War II, it was difficult to obtain ample quantities of certain foodstuffs. According to the minutes of the 80th Meeting of the State Board of Health Committee on May 14, 1946, "We are now getting more food than we did during the war period, but certain things, especially good quality meats, and particularly beef continue hard to get. The sugar rationing has limited the deserts we could serve because for them to be palatable, they must be properly seasoned." Overall, however, there were few serious complaints regarding meals served at Blue Ridge. Indeed, one patient wrote "The kitchen crew performs miracles while each patient's weight after a few months soars."

While there were thus changes in diet due to new developments in the study of nutrition and the food shortages of the wartime era, food remained an incredibly important part of the treatment regimen throughout the sanatorium's history. Even as antibiotics and chemotherapeutic agents, such as streptomycin, dihydro-streptomycin and paramino salicylic acid replaced the simple trinity of "fresh air, rest and good food," nutrition, and rightly so, continued to play an important part in the cure. For example, the 1955 manual A General Orientation for the Intern - Blue Ridge Sanatorium lists two important "General Treatment Measures." The first indicates that bed rest is the most important of all the supportive measures and should never be less than fifteen hours daily. The second suggests that a well-balanced diet and an abundance of fresh air are of paramount importance. "It is certainly no overstatement to say that thousands and thousands of cases have been cured by these measures alone. This is something to be borne in mind in these days of drug therapy and surgery," wrote the authors. Nonetheless, by the 1940s, popular and medical notions regarding appropriate treatment of tuberculosis were beginning to shift. According to the 1942 Annual Report:

The results of treatment showed the highest percentage of patients discharged as improved, and the lowest percentage of deaths in the history of the Sanatorium. This is particularly gratifying when we take into consideration the increased number of far advanced ill patients who have been admitted here. This clearly demonstrates that the treatment of tuberculosis is not simply a matter of general bed rest in the fresh air with proper dietetic regime, but this must be supplemented by active treatment in the form of various forms of collapse therapy, especially pneumothorax and thoracroplastic operations, as well as adequate treatment of other serious complications which may be found and that the modern treatment of this disease is not a question of 'camping out,' but is truly a hospital problem.

Regardless of such changing attitudes, good nutrition remained an essential component of the cure at Blue Ridge Sanatorium throughout its long history.

Indeed, even certain foodstuffs remained constant elements of the patients' diet from the sanatorium's beginnings until July 1, 1978, when the sanatorium closed and its facilities were transferred from the Commonwealth of Virginia to the University of Virginia Medical Center. For instance, milk was of great importance throughout the entire history of the sanatorium. This was actually somewhat ironic, as A Study of Tuberculosis in Virginia cites a bulletin on bovine tuberculosis issued in 1896 by the State Board of Health Virginia Veterinary Medical Association as the first official mention of tuberculosis in the Commonwealth. Irony aside, however, milk was indeed one of the staples of the patient diet. As lactose intolerance was not fully understood until the 1970s, patients who balked at drinking milk were simply told that they must train themselves to digest it. Margaret Rastetter remembered drinking five or more glasses of milk per day. One reason why milk may have been such an important part of the cure is that, according to a 1911 book by Oliver Bruce entitled Lectures on Tuberculosis for Nurses, a large number of tuberculosis patients suffer from one degree or another of dyspepsia. This is one explanation for why milk came to be seen as extremely beneficial in the treatment of this malady. Nonetheless, from the beginning, the physicians at Blue Ridge Sanatorium, unlike many of their counterparts, were careful not to force large quantities of food and milk on their patients. According to a Sunbeams article written in 1923, "forced stuffing with milk and eggs, beyond the demands of appetite and satisfactory gains in weight on more normal diet delays rather than hastens the cure." Nevertheless, patients were strongly encouraged to consume ample quantities of nourishing foods. During a talk given to patients at Catawba Sanatorium in 1917, Dr. J. L. Lloyd admonished "Drink five glasses of milk a day and as soon as you get used to resting outdoors you will find that your stomach can take care of this quantity of milk a day… Eat three good meals a day, and if you don't like what is put before you for the love of Mike don't say anything about it because it is bad manners."

Few patients bitterly complained as mealtime was one of the most eagerly anticipated times of the day. The sanatorium regime was strict and ordered, with meals being one of the only times during the day that patients were allowed to leave their beds. The daily schedule at most sanatoria in Virginia was as follows: 7:30am rising bell, 8:00-8:30am breakfast, 9:00-12:30pm rest in bed unless exercise is ordered by the physician, 1:00-1:30pm dinner, 1:45-4:00pm rest in bed - no talking or visiting allowed, 4:00-5:30pm quiet hour - rest in bed, unless exercise is prescribed by physician, 6:00pm supper, 8:00pm lounging on bed, 9:00pm ready for bed, 9:30pm lights out. While this schedule was taken from the Rules and Information for Patients pamphlet issued by Piedmont Sanatorium in 1940, not only were the daily routines at the sanatoria nearly identical, but they did not change in any significant way from the early days through the advent of streptomycin and other more modern treatments. The routine must indeed have been oppressive.

Well-balanced meals must have provided some measure of comfort to the patients who were isolated from friends and families for long periods of time, with the average stay lasting two years in the 1920s and 1930s, eight to twelve months in the 1950s and 89 days in the 1970s. The sanatorium, recognizing this, provided home-style meals and special feasts for Easter, Thanksgiving, Christmas and other holidays in an attempt to alleviate patients' feelings of ostracism and loneliness. According to the 1955 A General Orientation for the Intern - Blue Ridge Sanatorium, "The prospective patient is well aware of the fact his treatment is probably going to take several months … This means being separated from his family and friends, it means many lonely and monotonous days and weeks with himself, it means facing many fears and frustrations, and it means financial hardship for most patients." The sanatorium staff therefore endeavored to make the patients recovery as speedy and pleasant as possible. For instance, a description of the annual Fourth of July Bazaar in 1923 reads, "slightly to the rear, as to position, but in the forefront of attention were the dispensers of ice cream cones and coca cola." Special foods and feasts were thus prepared not only to nourish, but to comfort patients.

A well-balanced diet as part of the sanatorium regimen was of great concern at Blue Ridge Sanatorium, Piedmont Sanatorium and Catawba Sanatorium, three state-run sanatoria in Virginia. Along with salaries, some of the greatest annual costs of these sanatoria were food purchases. Similarly, at Blue Ridge the per patient per diem was $5.505 in 1952, $5.426 in 1953, $5.99 in 1954 and $6.608 in 1955, of which the patient food cost per diem was $1.396 in 1952, $1.392 in 1953, $1.354 in 1954 and $1.403 in 1955. In the 1950s, Blue Ridge and Catawba, established in 1909 as the first public sanatoria in Virginia, attempted to unify their food costs. According to the 1956-1958 budget proposal, "The committee was of the opinion that this rate should be uniform as far as Blue Ridge Sanatorium and Catawba Sanatorium are concerned, and it was suggested that the calculation of the food cost be delayed until the Committee Meeting was held at Catawba, when a uniform rate could be adopted." Food expenses were thus accorded much administrative attention and represented a significant part of the annual budget at all three sanatoria.

Indeed, the central importance of proper diet in the sanatorium experience is vividly illustrated by the fact that patients were classified according to their ability to take meals. Patients "up for meals" or "in to meals" were distinguished from those "on trays" and judged to be in better health because they were allowed to go to the main dining room for meals. The day that a patient was able to go to the dining room for breakfast, dinner and supper was a memorable day, signifying that the patient was on the road to recovery. For instance, the 1962 Catawba rulebook states that "Patients who are out to the dining hall to three meals daily, with permission from the physician in charge, may visit the Library and Recreation Room, attend moving pictures, Church services, etc.." Indeed during certain time periods of the institution's history, such as during the labor shortages of the 1940s, only patients who were ambulatory and could eat in the main dining room were admitted. The minutes of the 79th Meeting of the State Board of Health Committee held on May 22, 1945 indicate, "Patients applying for admission who were able to go on outside buildings and to the main dining room for their meals, have, in most instances been promptly admitted, but those needing infirmary care have had to wait sometimes for several months to be admitted." Patients were thus classified according to their ability to take meals and even granted or denied admission based on whether or not they were strong enough to eat in the main dining room during certain periods of the institution's history.
Similarly, patients were continually weighed with the thought that weight gains indicated improving health. For instance, as a general rule it was thought that patients should gain a pound a week until a weight of five or ten pounds over his or her normal weight was reached. Patients who gained weight were commended and held up as examples to their peers. The importance that weight played can be seen in the following account written by Rachel Heatwole, a twelve year old girl admitted to Blue Ridge Sanatorium in 1921. She noted in her diary, "When I went to Blue Ridge San. I weighed 70-1/4 lb. the first week I gained 2-3/4 lb. and the next I gained 1-1/4 lb. … The third week I lost ¾ lb. but gained it the next week and so it went some weeks I gained and some I lost and some I stood still …" Weight gain, like the ability to take meals in the main dining hall, was seen as a tangible sign of improvement. In order to promote weight gain and the proper chewing of foods, patients often had their teeth attended to immediately upon their arrival at the sanatorium. At Blue Ridge, for example, 291 patients were examined by visiting dentists and numerous extractions and filings were performed in 1925 alone. Weight gain was thus thought to be of paramount importance for individuals plagued by this wasting disease.
Not all patients received the same meals, however. As there were generally between 15 and 18 diabetics at the institution who required specially cooked meals, it was necessary to hire well-trained dietitians educated in the preparation of such special diets. In addition, customized meals were prepared for patients suffering from gastric ulcers, anemia and other conditions which would benefit from special diets. According to the 1955 Blue Ridge manual entitled A General Orientation for the Intern, the following special diets were available: "1- Diabetic diet, 2- Six-feeding gastric diet, 3- Low-salt diet (1,000 mgm And 2,000 mgm), 4- Low-residue diet, 5- Hemorrhage diet, 6- Liquid diet, 7- General diet, 8- Sippy diet." This menu of diets was, however, accompanied by the following caveat: "Special diets should not be ordered unless the need is real. The general diet, when suitable, is the best." One reason for this recommendation is that the culinary staff was limited and trained dietitians, who were often hard to find, were needed to prepare such customized meals. For instance, in 1950, due to staffing problems, a "lay woman" was in charge of preparing the trays. This led to uproar among the patients. According to a letter from Dr. Frank Stafford, Superintendent and Medical Director at Blue Ridge, to Dr. L. J. Roper, State Health Commissioner, "last week the situation became so bad that all of the diabetics refused to put up with it any longer and made a mass complaint to me." The preparation of meals for all patients, however, was taken quite seriously. In the 1953 annual report, the administration described the ideal candidate for the position of dietitian as "a young woman just out of school who had received her BS in Home Economics." Under the direction of the head dietitian, were cooks, a baker and various food service workers. In the 1950s, for instance, as many as 25 workers were employed in the culinary department. Food was thus taken quite seriously at the sanatorium.

The culinary department was housed in different buildings throughout the history of the sanatorium. For instance, when it was decided to enlarge the sanatorium in 1921, the Trinkle Building was constructed with a dining room. In 1926, the children's pavilion known as the Garrett Building was constructed at some distance from the other buildings. In order that the children would not have to make the long trek to the main dining room, a second building equipped with its own separate kitchen and dining room was erected directly behind the Garrett Building. It was found that children taking heliotherapy assimilated their food better and gained weight faster than those who did not. The children, however, were able to find their own ways of supplementing the diet at Blue Ridge. For instance, Juanita McGuire who entered the preventorium in 1945 at the age of thirteen recalled that visitors often brought gifts of food and that one time the children roasted marshmallows by setting fire to the trash in a garbage can. In 1938, Blue Ridge constructed the Hospital Building, a "fireproof" infirmary building with a 380 bed capacity which would also house the new culinary department. Previously, the culinary department was in the Nurses' Home. The new culinary department consisted of dining rooms for patients and employees, a kitchen, a dieticians' pantry, a diet kitchen, a bakery and a store room with cold storage in the basement. According to the minutes of the 76th Meeting of the State Board of Health Committee held on April 2, 1943, there were thus four diet kitchens. The report indicates, "Wright serves about 50 trays, the Trinkle about 40, the Infirmary 110 and the Garrett serves 40 children." By the 1950s Blue Ridge established a new Foods Laboratory teaching facility affiliated with the nurses' training program. In addition, by this time there were two pajama lounges on each floor of the main building equipped with refrigerators, hot plates and sinks for preparing snacks, representing a departure from the strict food regimen of earlier days. Over time, then, the culinary department's facilities evolved as the sanatorium expanded and new buildings were constructed, just as the patient diet evolved in response to changing theories regarding the cure regimen.
By the 1960s, however, it was decided that a professional food service firm should be hired to eliminate the management problems of retaining trained dietary department supervisors. In 1961, Blue Ridge signed a contract with Hospital Food Management, Inc., an affiliate of Slater Food Service Management. Hospital Food Management was later acquired by ARA Food Services, however it continued to run the dietary department until Blue Ridge closed in 1978. The sanatorium administration, surely relieved to no longer concern itself with culinary staff shortages, was largely pleased with the services offered by this food service provider. According to James Kennan's unpublished History of Blue Ridge Sanatorium, Hospital Food Management employees prepared and served "a variety of delicious foods which are well-seasoned Southern style and displayed attractively, whether on the cafeteria line or on patients' trays." Although the preparation of meals was thus turned over to a professional food service firm towards the end of the sanatorium's history, the patient diet remained a primary concern of the Blue Ridge administration.

The food at the sanatorium was indeed always of high quality, as not only the patients, but also staff members ate at the dining room. All doctors and staff members who lived on grounds were required to eat at the dining room, as were their families. Indeed, staff quarters were largely constructed without kitchens. Most of the solid foursquare Colonial Revival doctors' houses designed by Eugene Bradbury outwardly appear to resemble any other well-designed suburban residence of the day. However, the plans reveal otherwise, as the absence of kitchens and pantries is immediately noticeable. Staff members were required to pay for their meals. In 1950, the annual cost of three meals a day for adults was $365, or a dollar a day, while for children it was only $183 per annum. The physicians generally felt that the $1 per day cost for three square meals was just and reasonable. The fact that there was a one meal per day option indicates that workers commuting to the sanatorium could take their lunches at the dining room. Of course, food drawn from the commissary was "at cost." The quality of the meals at Blue Ridge was thus of great interest to the medical staff not just for the patients' sake, but for their own and their families' as well.

Food was of such great importance at the sanatorium, that patients who could not consume adequate amounts of food had it introduced into their stomachs in a procedure described in the 1954 Nursing Arts Procedure Book of Blue Ridge Sanatorium as "gavage." Nonetheless, most patients were happy to consume the meals prepared for them at the sanatorium, particularly as it was said that some patients, especially children, came to the institution greatly undernourished. Patients were not only given proper diets, but were also instructed in nutrition so that they might in turn educate their friends, families and neighbors upon their release from the sanatorium.

Nutrition education was considered to be of great importance in Virginia. According to a 1921 article published in Sunbeams, Virginia fought tuberculosis "by education, bulletins, literature, press reports, addresses and placards in the school, in the hoe, in the factory, in public carriers, along the roadside and through every open avenue of publicity." The education of children was considered to be especially important. For example, in 1923 the Nutrition Institute was held in Richmond under the auspices of the Virginia Cooperative Child Welfare Committee to address the often interrelated problems of tuberculosis and malnutrition in children by training workers to go out into the cities and counties to educate citizens. "Scales for Schools" was a slogan adopted by the Virginia Tuberculosis Association and Cooperative Education Association in the 1920s. Apparently, "The effect of weighing upon the children is very interesting. A child found to be underweight will soon learn to eat properly, sleep with open windows and follow directions generally if put on his mettle and impressed that it is 'his job' to bring himself up to par." The Commonwealth and the state-run sanatoria thus collaborated in the effort to educate Virginians about the importance of a proper diet in preventing and curing tuberculosis.

There were, however, no specific foods, other than milk perhaps, specifically recommended to speed the recovery of tuberculosis patients. Rather, protein, mineral elements, calcium and vitamins were stressed as elements of a wholesome and nourishing diet. In the late 1800s, various food cures, such as raw eggs eaten six times a day, were heralded as having the ability to heal victims of the disease. However, by the time Blue Ridge Sanatorium was founded in 1920, such fads had largely been abandoned and it was thought that three good substantial meals a day, with a glass of milk at and between each repast, was thought to be the most beneficial diet. A proper meal invariably included meat, vegetables and starches. Eggs with sausage or bacon was a popular breakfast, as was pancakes accompanied by ham. Lunch often consisted of a hearty sandwich, while dinner was generally the standard "meat and potatoes" fare so popular until very recently. Fats, after all, were considered to be extremely beneficial and nourishing. According to a 1924 article in Sunbeams, "The food the patient takes should be easy to digest, prepared in a plain way without spices and hot sauces; such things only tend to stimulate the patient and he is defeating his purpose of rest. In general, his diet should consist of milk, eggs, fruits, cereals, vegetables, breads and meat in moderation." The goal of the sanatorium, however, was not just to make nourishing meals, but to make appetizing meals, as many patients, especially those with a slight fever, had lagging appetites. Nonetheless, just as overstimulating diversions were forbidden patients, so were overstimulating rich or spicy foods. The patient diet and overall cure regimen were thus inextricably interwoven, developing hand-in-hand over the course of the sanatorium's long history.


VI Conclusion

As we have seen, then, throughout the history of Blue Ridge and other Virginia sanatoria, the "rest, fresh air and good food" cure espoused by Drs. Edward Livingston Trudeau and Alfred Loomis at their pioneer sanatorium in the Adirondacks affected both the physical development of the institutions and the evolution of the cure regimen. Trudeau and Loomis' treatment recommendations impacted not only the site selection for tuberculosis institutions, but also influenced their physical development in terms of the construction of buildings and the landscaping of the natural environment. That is, secluded rural sites were chosen, as they were thought to provide wonderful healing environments conducive to the long hours of bed rest and healthful country air considered necessary for recovery. In terms of construction, early patient pavilions, such as those constructed in the 1920s at Blue Ridge, were directly modeled after the Saranac Lake cure cottages with south-facing porches open to the elements where the first patients spent their days regardless of the weather. Even as surgery, antibiotics and chemotherapeutic treatments began to replace the more homeopathic treatments first employed at sanatoria, hospital buildings still reflected, though to a lesser extent, tenets of the Outdoor Life. That is, even the 1949 addition to the main hospital building at Blue Ridge incorporated large windows and an airy solarium with southwestern exposure. In addition to affecting the construction of buildings, however, the "rest, fresh air and good food" mantra also influenced the landscaping of tuberculosis sanatoria, particularly in the early days. Perhaps consciously or unconsciously, the Blue Ridge administration advocated a pastoral landscape design featuring field-like lawns and curving pathways. Indeed, prior to 1939 when the new farm complex was constructed at some distance from the main campus, cows grazed in the pastures directly behind the sanatorium buildings and there was little separation between open fields associated with Blue Ridge's farming operations and the pastoral landscape of the main campus. Thus, both the architecture and landscape architecture at sanatoria such as Blue Ridge reflected the basic tenets of the "rest, fresh air and good food cure" throughout their history, more strongly at first but still quite visibly in later years.

Similarly, nutrition played an important role in the sanatorium experience from the founding of these early sanatoria right up until their dissolution. While the nature and quantities of foods necessary to cure the afflicted varied greatly over time, proper nutrition, however that was defined, was always an integral part of the cure regimen for this wasting disease. Milk, however, was always viewed as a healthful staple for tuberculosis patients, and, as we have seen, many sanatoria operated extensive dairy operations in order to supply their patients with abundant quantities of farm fresh milk. Even after the 1944 discovery of streptomycin, the value of good nutrition in both preventing and healing tuberculosis was stressed by sanatorium medical staff. Thus, hand-in-hand with changes in the settings in which the tuberculosis was treated, the role of nutrition in the treatment of this dreaded disease evolved in response to medical advances, all the while, however, incorporating the "rest, fresh air and good food" regimen of the late 1800s.

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