The Great White Plague:
The Culture of Death and the Tuberculosis Sanatorium

by: Richard Sucre

Introduction

Tuberculosis was one of the leading causes of death in the United States in the early twentieth century. Those infected with tuberculosis were isolated from society and placed in sanatoriums. These self-contained communities became known as "waiting room[s] for death." As described by historian Sheila Rothman, death was synonymous with tuberculosis and was an ever-present characteristic of the sanatorium:
"However much the sanatorium resembled other institutions, it had one unique feature- the omnipresence of the shadow of death. Apart from it, nothing can be understood about sanatorium life, whether it was staff enforcing rules or patients seeking sexual pleasure. Staff tried to brush it off with aphorisms about being strong and determined. But in countless ways, some personal, others collective, the sanatorium experience was at its core an encounter with mortality."

However, even though society related tuberculosis with death, the landscape and architectural design of the sanatorium did not reflect this strong association. This can be seen with two Virginia sanatoriums, Blue Ridge and Piedmont (see Fig. 1 and Fig. 2). At these institutions, there were no architectural representations of death within the sanatorium landscape such as mortuaries, morgues, funeral homes, cemeteries, crematoriums or gravestones. In addition, the social and communal acknowledgment of death was also suppressed within the sanatorium community. This suppression of death in both the built and communal environment of Blue Ridge Sanatorium stands in direct opposition to the architectural representations of death within the city of Charlottesville.

Morbidity, Mortality, Tuberculosis, and the Sanatorium

An estimated 110,000 Americans died each year from tuberculosis in the 1900's. The tuberculosis mortality rates of Virginia were one of the highest in the nation. In 1908-1909, an estimated 12,127 people were infected with tuberculosis. The establishment of the Virginia Anti-Tuberculosis League and the reorganization of the State Board of Health in 1908 provided the political background to the opening of the first state-sponsored sanatorium in Virginia, Catawba Sanatorium in Roanoke, which admitted its first patient in 1909. The opening of the first sanatorium signified a response from the state to the increasingly deadly nature of the disease felt across the nation.

By 1913, the state of Virginia became an official registration area for the disease. The state began to track the number of patients who died of tuberculosis each year (see Table 1). According to a pamphlet published by the Virginia Anti-Tuberculosis Association, Lost: 5,000 Men & $25,000 in Virginia, the control of the disease depended on tracking the mortality and morbidity rates (see Table 2). This information became key propaganda for levying for more sanatoriums in Virginia.

On April 22, 1918, the second state-sponsored sanatorium, Piedmont Sanatorium, opened in Burkeville, Virginia for Negro consumptives. Previously, the only treatment facilities for black patients were in state mental institutions, where the hygiene level and quality of treatment were very poor. A report from H.G. Carter, director of Piedmont Sanatorium, states:
"It is up to the white man who controls his destiny to see that he [the Negro] gets the proper treatment when sick; for the sake of humanity first, from an economic point of view second and for his own sake and that of his family if he sees no other reason"

The state concern for the black tuberculosis problem arose because many Negroes worked intimately within white households thus the disease could be spread to both white and black populations. Tuberculosis was a major problem within the black community and black tuberculosis mortality rates were always larger than the mortality rates of the white population. For example, the state of Virginia had a total of 30, 652 (18,551 white, 12,101 black) deaths in 1920. Of this number, there were 1,545 white tubercular deaths and 1,774 black tubercular deaths. Even though, Piedmont sanatorium opened with only 22 beds in 1918, the affects of treatment became apparent in the lower mortality rate of the following year (see Table 1).

The State of Virginia recognized the need for another white sanatorium because beds were occupied year round in both Catawba and Piedmont Sanatoriums. After approval from the State, the Blue Ridge Sanatorium opens in Charlottesville on April 26, 1920 with 112 patients. After one year of operation, there were a total of 229 discharged and dead recorded from April 26, 1920 to September 20, 1921. In the initial data concerning discharged patients, the number of dead patients was part of the discharged number (see Table 3). The sanatorium masked the number of deaths into their discharge numbers thereby screening the number of deaths in the sanatorium. The affects of the treatment from all three Virginia sanatoriums was visible in the lower tubercular death rates of 1924, which was 27% lower than the 3,727 deaths of 1915.
By 1922, a new standard for classifying patients was introduced. The patients were classified into groups such as "Far Advanced, Moderately Advanced, Minimal and Non-Tubercular and Untreated." The number of deaths within each of these groups was recorded, with the highest number occurring in the "Far Advanced". An "Untreated" patient resided in the sanatorium less than thirty days. These numbers were always separated because thirty days was considered too short of a time period to allow for an effective cure (see Table 3). Other statistics were also recorded such as the average age of death, the length of stay in the sanatorium, weight, sex, occupation, race and originating Virginia County.

The doctors thought that there was a connection between the disease and a physiological characteristic such as age, weight or sex. In 1922, the high death rate in the young (maximum mortality rate of twenty to twenty-five) was attributed to the lessened resistance from the lack of contact with tuberculosis while the high death rate in the middle aged (maximum mortality rate of forty-five to fifty-five) was "due to a more chronic form of the disease from previous infection".
The economic cost of the death of a patient in the tuberculosis sanatorium was a major concern of the state of Virginia. In 1927, the estimated cost of a tubercular death was approximately $ 8,000. The dollar amount represented a loss in wages, a lost in cost of care, the contribution of the individual to the future economy, and the cost of the individual's burial. Economically, the state viewed each patient as an investment in the society.

As new treatments developed, mortality and morbidity rates were once again used as propaganda for advancing the tuberculosis movement. In 1953, the study of tuberculosis conducted by the American Public Health Association (APHA) advised the Virginia Board of Health about expanding upon a tuberculosis strategy. The study recommended the use of this report to develop public interest in the disease as well as to establish an Advisory Tuberculosis Control Committee. The study also suggested increasing research facilities and expanding treatment facilities to include an additional 3,600 beds for both white and black tuberculosis patients. Rather than tracking the number of successfully cured individuals, the focus of the studies revolved around death (see Fig. 3 - 5). The project used mortality rates related to race, locale, sex, and age to explain the impact of the disease in the past decade (from 1939-1951, see Fig. 6 - 10). The studies showed a correlation between predominately black areas of Virginia and a high concentration of tubercular individuals (see Fig. 8 and Fig. 9). The non-white death rate is nearly triple the white death rate from 1940 to 1951 (see Fig. 7). Inevitably, the study concluded that the mortality and morbidity rate were declining due to the new surgical treatments available and antibiotic/drug treatments.

The study of the morbidity and mortality rates promoted the sanatorium when the primary cure was bed rest and open air. As the treatment for the disease evolved towards outpatient medication, mortality and morbidity rates declined. The open-air cure offered by the sanatorium no longer had significance in relation to the modern treatment. Though interest in the tubercular dead had an effect on the political and economic atmosphere surrounding the creation of the sanatorium, the interest in the dead did not directly translate into the architectural character of the two Virginia sanatoriums.

Initial Entry & the Rules of the Sanatorium

The initial application into the sanatorium acknowledged the possibility of death. On the entry application, there was a question about permission to perform an autopsy. The autopsy acknowledged the possibility of death. The medical community used autopsies to explore the post-mortem tubercular body. An autopsy was not preformed on every individual due to religious beliefs and educational background. In the Jewish religion, autopsies are not permitted upon dead bodies because the body is not to be violated in any form. For some black patient, signing the autopsy permission meant they signing permission to die in the sanatorium.

Upon acceptance of an individual's sanatorium application, the nurse asked for advanced payment to cover time in the sanatorium and to pay for a return ticket home. The ticket home was for the patient, if the expectation of death was apparent while in the sanatorium. In some cases, near death patients were allowed to go home to die. There was dignity associated with dying at home. The cost of the ticket home was also to cover the transport of the patient's corpse if they happened to die in the sanatorium. Both staff and patient prepared for the expectation of death in the sanatorium.
The nurse proceeded to introduce the patient to the strict rules and the treatment provided by the sanatorium. The emphasis on the cure was "Rest in Bed" in the open air on sleeping porches or in well-ventilated rooms. There were strict rules governing coughing in public, spitting on the floor and basically controlling any potential spray that came from the lungs, throat or mouth. Exercise was stressed as speeding up "…the end of many of those now dead from tuberculosis". The patients were instructed to never get out of breath, never exercise when the temperature is above 99.6º, never exercise if sputum was streaked, never run or walk fast, never get tired, and never attempt mountain climbing. The emphasis was placed on the individual and how he/she could facilitate their own cure by following the sanatorium rules. The Piedmont Sanatorium Rules and Information for Patients said, "If you expect to get well you must work for it".
In 1920, the Daily Schedule for patients of Catawba Sanatorium according to the Rules & Information was as followed:

7:15 - Rising Bell
8:00 to 8:30 - Breakfast
8:30 to 11:00 - Rest or Exercise as Ordered
11:00 to 12:45 - Rest on Bed
1:00 to 1:30 - Dinner
1:45 to 4:00 - Rest on Bed, Reading but no talking allowed. Quiet hour.
4:00 to 5:45 - Rest or Exercise as Ordered
6:00 - Supper
8:00 - Nourishment if ordered
9:00 - All patients in pavilions
9:30 - All lights out

Similar regimented schedules were at both, Piedmont and Blue Ridge Sanatoriums. A patient of Blue Sanatorium, Rachel Heatwole, recounts her experience in her diary and said in November 1st, 1921 entry: "…No we are not allowed to sleep in our rooms we can only move in our bed in quiet hour and until nine. It is pretty cold here sometimes". The patients followed the rules of the sanatorium with the hope of someday leaving healthy.

The social atmosphere was also regulated by the rules and information for patients. Patients were instructed to not complain to fellow patients about their condition. The rules stated "Conversation between patients about their disease, symptoms, or any subject relating thereto, is forbidden during meals, and is discouraged at all times". This rule also carried over into the discussion of death among patients. Death was not to be discussed and patients were told to try to keep a positive frame of mind. The sanatorium environment required the individual to follow the rules thereby facilitating the cure.
Though the application to the sanatorium acknowledged the possibility of death, the boundaries of the sanatorium folded death into the culture of rest and control. The same rules that regulated the reference to death also inhibited the appearance of death within the architecturally environment.

The Sanatorium Social Atmosphere and the Death of a Patient

According to the rules and information for patients in both Piedmont and Blue Ridge Sanatorium, patients were required to keep quiet about their condition. This same silence translated into the view of death at both sanatoriums. There were no communal services given by patients in the sanatorium. Even though individuals did mourn the death of a friend, the sanatorium did not sponsor any official grief counseling or outlet for bereavement. Rachel Heatwole wrote about the death of Dr. Frank Stafford's wife, who the children of the sanatorium admired, in her diary. Rachel wrote, "…everyone was upset and even we children felt very sad. Some of us wanted to have her come back to life so we went into a cloakroom and prayed about it". One had could not display the emotional outbursts associated with bereavement because that would not be conducive to their cure.

Even though patients mourned silently over the death of another patient, the staff was required to remain apathetic to the death of a patient. In the recounts of Merrit D. Burton (also known as "Dippy"), a former patient and staff member, he wrote,

"One time when I was only twenty-two myself, there was a young man about twenty-eight who was very ill… He began to talk about his life…He began to tell me what his plans were for the day he'd be getting out… That same night he had a small hemorrhage and died about seven o'clock."

Dippy later wrote:
"One snowy Sunday night in 1940, I came on duty without wearing my galoshes…We went over to the Wright Building…When he got back, they told me 'Come here. This one's not going to be here much longer.' Later 'one going out' on Second Floor. Still later, we lost another. Four patients died in that one night."

The staff encountered death and had to maintain composure in the sanatorium environment. The staff was restricted from telling any patient about the death of another patient.

Similar to the rules given to patients, the nurses were instructed to follow strict regulations and rules of conduct upon an encounter with the deceased. The nurse's primary objective was to make the body, especially the face, look as natural as possible. The nurse's instructions were to:

· Keep knowledge of death from other patients - be quiet and composed tactful and professionally sympathetic - no details - nurse should be composed, sympathetic and efficient
· Be considerate of family members and handle the situation as if they were present
· Leave body in best possible condition: for example placing false teeth in mouth and elevating head on pillow, closing eyes, cleaning nails, combing hair
· Have all belongings sent with body
· Notify switchboard, diet kitchen and Director or Nurses offices
· Remember that the body IS CONTAMINATED and treat it as such, particularly those with tuberculosis
· Undertaker is to sign two death certificates to leave in the chart - signed by a qualified register
· Notation of "Respiration ceased at ______ A.M." on chart

The nurse acted as the mediator between the dead and the living. The corpse had to maintain an image until the body could be removed. The nurse was responsible for keeping up the image of the body. The nurse proceeded to contact a doctor and prepared the material for disposal of the body, which included linen for the body as well as the death certificate, so that the body could be transported to the proper place for interment.

The death certificate was extremely important in processing the dead (see Fig. 11). According to the guidelines of the Virginia Board of Health, the death certificate needed to specify: place of death, full name, sex, color/race (white, black, italian, chinese, japanese or other), conjugal condition (single, married, widowed or divorced), date of birth, age, occupation, birthplace, name of father, birthplace of father, name of mother, birthplace of mother, mother's maiden name, and address. In shipping the dead, the cause of death was included on the death certificate (see Fig. 12). By labeling the body as tubercular, precautions were taken to protect the public from infection. According to the Report of the State Board of Health of Virginia in 1905-6:

"3. The bodies of those dead of typhoid fever, puerperal fever, tuberculosis, or measles may be received for transportation when prepared for shipment by arterial and cavity injection with an approved disinfecting fluid, washing the exterior of the body with the same, and enveloping the entire body with a layer of cotton not less than one inch thick, and all wrapped in a sheet securely fastened, and encased in an air-tight metallic coffin or casket, or air-tight metal-lined box: provided that this shall apply only to bodies which can reach their destination within thirty hours from the time of death"

With the death certificate completed, the body was transported to a local funeral home (see Fig. 13).
After a conversation with Dr. Kenneth Heatwole, who served at the Blue Ridge Sanatorium as both a patient as well as a doctor, the sanatorium handled the dead by contacting three different funeral directors in the Charlottesville area on a rotating schedule. The doctor was instructed to contact an undertaker of the family's preference. If there was no preference, the doctor contacted three Charlottesville undertakers (Preddy's, Hill & Irving and M.C. Hill) on a rotating schedule.

The social atmosphere of both the patients and staff as related to death displayed the silent power of the sanatorium. By scripting the handling of the dead in the sanatorium, control was exerted over the appearance of death in the community.

The Sanatorium and the Spaces for the Dead

Although there were not larger representations of death, the sanatorium had subtle indications hidden within larger architectural landscape. Rather than devoting an entire building to the dead, the sanatorium used single spaces within the architecture to accommodate the possibility for death.

There were two autopsies performed at Blue Ridge Sanatorium as shown by the 1950 survey by the Bureau of Hospital Surveys and Construction. Since, there were no morgues in the sanatorium , one can infer that autopsies were performed within operating rooms. The requirements for an autopsy space included areas for medical equipment and chemicals as well as storage space for bodies. The doctors required a table for the corpse. The operating rooms within the Wright Pavilion and the East Wing of the Infirmary are assumed to be large enough to accommodate the necessary requirements for an autopsy (see Fig. 14 and Fig. 15). Thus, the operating room, the space for repairing the body, and the autopsy laboratory, the space for exploring the body were woven into one another.

At the two sanatoriums, the private room or the single room contained the patients with the most advanced cases of tuberculosis. The single room removed the sickest individuals from the rest of the sanatorium community because death was imminent in many cases. At Blue Ridge Sanatorium, the Wright Pavilion and the East Wing of the Infirmary had single rooms used for advanced tubercular cases (see Fig. 14 and Fig. 15). At Piedmont Sanatorium, the Randolph Pavilion and the Moton Pavilion contained rooms at the end of the long, single loaded corridors that could be closed off to create single rooms (see Fig. 16 and Fig. 17). The common features in the single rooms at both sanatoriums were the lack of direct access to the sleeping porches as well as the location at the ends of the buildings. The planning of the single rooms in each of the buildings mirrored the presence of death within the sanatorium community. Death was placed at the periphery of the sanatorium community. The Rules and Information of Patients controlled the communal environment of the sanatorium and the isolation of the patients about to die displayed the communal control of the rules. The private room became a reflection of the unseen presence of death within the larger sanatorium landscape.

The Culture of Death in Society

In comparison to the representation of death in the sanatorium, society acknowledged the role of death as part of the community. The presence of the undertaker and funeral homes in the city demonstrates the clear role of death in society.
The undertaker's responsibilities included the removal of the corpses from the sanatorium. The ability to provide transportation for the dead was the key element to the undertaker's service. As part of their advertising, the automobile was featured as a key part of the undertaker's businesss.

The business of the undertaker was formally acknowledged by the State in the early 1920s. Previously the undertaker was a part-time position that carpenters and liverymen accepted in addition to their normal tasks. The undertaker was responsible for the preparation of the corpse including presentation and embalming. As undertaker evolved into the funeral director, society's concern for the dead changed to focus on the dead as well as the living. The orchestration of the funeral was the main factor in evolution of the funeral director. The funeral directors responsibilities included presentation of the body, ceremony for the deceased, arrangement of the final resting place for the deceased, floral arrangements, the obituary, and transportation.

The funeral is the main bereavement ritual for the living. As defined by Dr. William Lamers, Jr. , the funeral is an organized, time-limited flexible, group-centered response to death. The funeral involves many different people including the undertaker, the medical examiner, a funeral director, an embalmer, the coffin-maker, an obituary writer, the hearse driver, the cemetery workmen, and even the psychologist. The funeral director functions as many of these people in order to minimize the worries of the bereaved. The main function of a funeral is to allow a psychological closure for the living. The presentation and preparation of the body is a social construction of the twentieth century. The funeral allows for the construction of a memory picture. The memory picture is the last glimpse of the deceased in an open casket. American custom requires the presentation of the dead in a semblance of normalcy.

Utilizing the home in connection with the funeral, death became less harsh and brought into the everyday. The funeral home became the working environment for the funeral director. The location of the funeral home within the city demonstrates the role of death in society (see Fig. 18 - 22). The funeral directors of Hill & Wood are currently located at Market and 1st in the Downtown of Charlottesville, Virginia (see Fig. 22). Charlottesville's main commercial and governmental regions are part of the Downtown area. The development of the Hill & Wood Co. from the part-time undertaker to the full-time funeral director was an example of the changing attitudes towards death within the general public. Hill & Wood originally began as the Hill, Way & Irving Company in 1907 (see Fig. 20). Mr. Willard Irving handled the livery business, Mr. C.T. Way was the carriage maker and J.Hercules Hill was the undertaker. The original location of their business was on the east end of Water and Main Street; the main commercial district was west and the train station was to the south of their location. Their property included carriage wood working machinery, livery, office space and a repository for undertaking. The undertaker was part of the main commercial district of the city (see Fig. 21). In 1929, Hill, Way & Irving became the Hill & Irving, Co. By 1936, the funeral home moved to the house at the corner of Market and 1st Street (see Fig. 23 and Fig. 24). This new location has been historically residential as well as within proximity of religious buildings; the Presbyterian Church, the Jewish Synagogue, R.C Church and Disciple's Church are within two blocks of the funeral home (see Fig. 25 and Fig. 26). The residential appearance of the new location was drastically different from the commercial office and livery space of the previous location. The company's change from undertaker to funeral director was signified by the shift in location and change in appearance. The funeral director wanted their business to reflect the new association with the home that was prevalent among other funeral directors.

The presence of the funeral home within the downtown recognized the culture of the death in society. The funeral home was embraced and recognized as a necessary part of the community. This is in sharp opposition to the sanatorium, which hides death in a mask of silence.

Conclusion
The culture of death in society did not translate into the architectural environment of Blue Ridge and Piedmont Sanatoriums. The social rules of the patient and staff reinforced the concealment of death in the sanatorium. In order to provide a cure for individuals, death was obscured and patients were denied a physical reminder of the morbid possibility of their disease.