The Cure Cottages

by: Roysin Billett

Aptly described in the 1915 report of the Tuberculosis Commission of the State of Virginia, "The sanatorium is…nothing but a hospital so constructed that its inmates can live continuously in the open air while well protected against the elements." A commonplace observation in 1915, a generation earlier it could not have been conceived. Before the identification of the tubercle bacillus in 1882 as the scientific cause of tuberculosis, and before the first American sanatorium opened in Saranac Lake, New York in 1884, diagnosis and treatment of tuberculosis lacked consistency. Often doing more harm than good, treatments mingling medical and lay products were administered to patients at home in dark, overheated rooms. The treatment introduced at Saranac Lake by Dr. Edward Trudeau was a radical departure from these stifling sickrooms. Pioneering in the United States a treatment initiated by German doctors Brehemer and Dettweiler who offered the first open-air institutional treatment of lung diseases in the mid-nineteenth century, Dr. Trudeau endorsed "an invigorating climate, an open-air life, rest, …careful regulation of the daily habits and an abundant supply of nutritious food," as the recipe for recovery from tuberculosis. "The cure," as the treatment came to be known, relied on the "cure cottage," a simply constructed dwelling, reminiscent of seasonal camp architecture, where patients could fill their lungs with continuous fresh air, reclining on a porch. (Fig 1, Fig 2) The success of this treatment resulted in its widespread adoption, so that by 1915 when the Tuberculosis Commission of the State of Virginia described the design of the sanatorium, open-air treatment of tuberculosis was firmly established.

Thomas Spees Carrington's 1911 handbook for sanatorium design reflects the proliferation of open-air institutions for the treatment of tuberculosis across the country. The handbook offered guidelines for all aspects of sanatorium design, including patient quarters, where the adoption of Trudeau's principles is clear. Cure cottages, much like those found at Saranac Lake, were recommended for private institutions: "Well to do patients usually desire separate apartments, and often demand a porch which is private and cannot be overlooked by other inmates of the institution." (Fig 3, Fig 4) For state-run sanatoriums limited by funds, a modification of the cottage allowing for greater capacity and less expense resulted in the pavilion. This modification took the form of two open lean-tos placed end to end, connected by a sitting room, with a locker and dressing room as a rear extension located directly behind the sitting room. (Fig 5, Fig 6)

The materials, orientation, and ventilation of these lean-to pavilions followed a basic proscription, as outlined by Carrington. The debate of a permanent over an impermanent material for construction was a basic issue of cost. The overwhelming majority of pavilions were of frame construction. The porch was the distinguishing feature. Allowing for year-round ventilation at all times of day, it needed to be wide enough to accommodate free movement at the foot of the beds, with a clear space for a reclining chair. The depth of the porch needed to protect patients from storms and high winds, as it was entirely open to the elements, and was suggested to be three times the length of a bed, eighteen feet or more from the rear wall to the opening. The earliest pavilions might be protected by canvas awnings, which were eventually replaced by screens and/or sash windows. (Fig 7) Orientation of the porches was of utmost importance. The preference was for a southeastern exposure, to avoid direct southern exposure, which could make for uncomfortably warm conditions. While orientations varied from south, to southeast, to southwest, nearly all enjoyed some variant of a sunny southern exposure.
Carrington's recommendations as well as the situation of the roots of the cure cottage in a rustic summer architecture inform the pavilions at Piedmont and Blue Ridge. Plans for the pavilions do not exist, and the buildings themselves have long since disappeared from their sites, but with the aid of Sanborn maps, written descriptions, photographs and postcard renderings, a picture of these pavilions begins to emerge.

Though Piedmont and Blue Ridge as state institutions were limited by their funds, design as well as economy factored into the initial planning stages of the pavilions. Board of Health Minutes reveal that the pavilions at Piedmont were to be "placed with an eye to future development, architectural effect, and, above all, to sound institutional economy." [Italics mine]. Similarly, conversations regarding the design and situation of the pavilions at Blue Ridge included aesthetic considerations:
"Various arrangements were suggested for grouping the buildings. The desire of the committee was registered that rigidity of grouping should be avoided and that the facing or frontage of each building to be planned for should be considered in advance with the object of providing a certain degree of individuality to each building. A modified horseshoe type of building was suggested for the structure at present being planned for."

In the end, economy trumped design and single story frame structures roughly following Carrington's footprint of a central core flanked by wards were constructed on both sites. (Fig 8, Fig 9, Fig 10)
Sparing expense was at the heart of the design of the Randolph pavilion, the first to be constructed at Piedmont in 1917, which depended upon "opening the whole of the front rather than hav[ing] a porch, since this reduced the expense very materially."

According to a contemporary description of the building, a long corridor entirely open on the south side, contained central dressing rooms, and at either end were wards of four and six beds for ambulant cases. Off the corridor in a rear extension were a set of rooms which could be closed for far advanced cases, or could be left open, as conditions permitted. (Fig 11) A total of twenty-five beds were accommodated. Heavy curtains could be pulled down in inclement weather. No mention is made of bathing facilities in early accounts, but a 1921 description mentions "the usual water sections," in the "warm corridor" at the rear. This location is consistent with pavilion plans that appear in Carrington. (Fig 5, Fig 6)
The design of the Randolph pavilion was modified in the Moton pavilion, constructed in 1918 at Piedmont, to include a full porch on the south side, fourteen feet wide, with an overhanging roof, as well as two small rooms on the north side, likely washrooms. The Moton pavilion retained the central rear extension of the Randolph pavilion, and it probably preserved its use for advanced cases, at least until the infirmary was constructed sometime before 1929 when it appears on the Sanborn maps. Every patient on this pavilion had a room into which he could be moved. (Fig 12) The new building accommodated forty beds. The addition of the Moton building to the Piedmont campus allowed for more complete segregation of the sexes than was possible in a single building. The Randolph pavilion was adopted for women, the Moton for men. At this juncture, the Randolph pavilion may have undergone internal rearranging, as a 1921 description notes that the corridor consisted of a series of two-bed rooms.

The Addison, Strode, and Thomas pavilions at Blue Ridge, constructed in 1919, resembled the Moton pavilion in plan. (Fig 13) This can be attributed to the fact that the two sites shared an architect, Charles Robinson, and that the Albemarle Tuberculosis Sanatorium Sub-Committee approved "the type in use at Piedmont" for their frame buildings. Also accommodating forty beds each, with individual rooms to be shared by two patients off of the porch, it is likely that the similarities extended to the rear portions of the building, probably used for washrooms and advanced cases, at least until the Trinkle Infirmary was erected in 1922. As at Piedmont, multiple pavilions allowed for the segregation of patients by sex, and with an additional pavilion at Blue Ridge, also by age. In the early years, women were placed on the Strode, men on the Addison, and children on the Thomas. A young girl on the Thomas pavilion in 1923 described the layout as follows:
"My first room struck me immediately as being so empty. There was no bed, no carpet, only two chairs and two chests-of-drawers…to the left and right of the double doors which led to the hallway were closets with a curtain over the door. On the opposite wall were glass doors which opened onto the porch. There were the beds, a long row of them with the nurses' station at the center."

Given the likeness in plan of the Blue Ridge pavilions to the Moton pavilion, this interior arrangement might serve for both.
While the two sets of pavilions share an economy of construction material, and similar footprints, they differ in their siting. Piedmont's densely wooded relatively flat site contrasts with Blue Ridge's open, rolling topography, nestled at the foot of a mountain. The arrangement of the pavilions is a further distinction. Piedmont constructed a brick administration building flanked by two frame pavilions, a rather hierarchical organization both in building materials and arrangement. (Fig 14) Conversely, the pavilions at Blue Ridge did not flank the administration building. Rather all three were staggered to the south of the building. Despite economy dictating their plan and building material, the Blue Ridge pavilions avoided "rigidity of grouping," and while they were identical, the staggered arrangement allowed for "a certain degree of individuality to each building." Rotating the buildings to the southwest, each pavilion maintained its own sight line of the natural setting. (Fig 15) This arrangement not only fostered some degree of individuality among the buildings, but also a more "natural" and less regimented air.

Of frame construction, a central core flanked by wards, open, and facing south, the pavilions at Piedmont and Blue Ridge, then, reflected Carrington's recommendations for patient quarters. Each set of pavilions also expressed its descent from a seasonal architecture. Simply constructed, simply furnished, single story structures with overhanging eaves, open to the elements, these buildings related closely to the land. Timber construction was unquestionably the least expensive, but it is also leant the pavilions an air of having come from the woods. The addition of stucco to the wood frame at Blue Ridge, though perhaps less natural than wood, retained its charm nonetheless. Stucco was approved in a guide to small house design from 1923, for example, for suggesting "an age old atmosphere." Outfitted with handmade stools, bedside tables, clothes cabinets and makeshift dressers, the furnishings of the pavilions further recalled the atmosphere of the camp where "the first requirement of camp furniture is utility, not appearance…" (Fig 16) Additionally, the long, low arrangement of these single story buildings maintained physical connection with the land, as these buildings were barely raised from the ground. Implications of stepping from porch to ground without ascent or descent that appear in contemporary domestic literature apply also to the pavilions: "This identity of level adds to the feeling of unity with outdoors and in a sense ties the porch to its surroundings." Further, the overhanging eaves suggested shelter, and because they extended below the plate of the wall, they drew the eye down, back to the ground, rather than up to the peak of the roof. Lastly, the initial lack of screening and glazing of the pavilions literally brought the outside in.

Importantly, Charles Robinson had been engaged in design (though not of pavilions) at Catawba Sanatorium, the only other state run sanatorium in Virginia, just five years before he was to begin work at Piedmont. The early sanatorium landscape of Catawba was a local precedent for the camping out quality of life of the sanatorium. The 1910 Virginia Health Bulletin advertised:

"At this Sanatorium, patients practically live out-of-doors. The female patients live in a large 'lean-to' situated on the lawn. This building is so constructed that the patients sleep in the open air, take their recreation in the open air and only go occasionally into the house. The male patients live in a similar small lean-to…and in a number of walled tents…All the patients with but a single exception have been greatly improved by their stay at Catawba."

If life on the pavilions was reminiscent of the camping experience, life on the tents was the camping experience. (Fig 17) While tents were never constructed at either Piedmont or Blue Ridge, Robinson's familiarity with the earliest pavilions and the nature of "taking the cure" at Catawba is evident in his designs for the sites.

The impermanent architecture of these early buildings is an expression not only of economy, or the fresh air treatment modeled on outdoor living, but of the haste to provide treatment. In an Act of the General Assembly passed in 1908, the urgency to separate those infected from those who were not, resulted in the proclamation that "suitable rooms, apartments, or tents shall, where practicable, be provided by the Board of Supervisors of the county, the councils of the city or town…" One month later the act that established the State Board of Health announced, "It shall be the duty of the State Board of Health as soon as practicable to begin the erection and maintenance of temporary or permanent buildings or camps for the treatment of tuberculosis." This sentiment persisted as late as 1947 when Governor William Tuck wrote to the Virginia Tuberculosis Association:

"I am most anxious that we, at the earliest practicable date, work out some plan to hospitalize all those afflicted with tuberculosis…we must, in my opinion, abandon the idea of building tall brick buildings…it is my contention that they would be better off housed, and separated…than to let them die while we are waiting for brick buildings…"

The repeated appearance of the phrase "as soon as practicable" underscores the priority given to housing patients and beginning their treatment, the quality of construction and type of building a secondary consideration.
Born out of a sense of economy, urgency, and modeled on a seasonal architecture, it is not surprising that the pavilions at Blue Ridge and Piedmont were a source of consternation almost as soon as they went up, and continued to plague the Administration until they came down. Months after the Randolph pavilion opened at Piedmont, disappointment with the building was clear, "…we have put up an inexpensive pavilion for patients, which is somewhat of an experiment, and already shows that it has bad features…this building demands too many things at once." The Moton pavilion was considered an improvement on the Randolph when it went up a year later, though the "water sections" in the rear were thought "not very well planned," and "quite inadequate." Likewise, even before the Blue Ridge Sanatorium opened, Charles Robinson reported at the Committee meeting that some of the stucco plaster had fallen off from one of the patient's buildings and would need replacing. Shortly after opening, the Report of the Medical Director of Blue Ridge noted:

"In connection with the general sanitation of the Sanatorium the question of flies has been a serious problem and during the hot weather, the patients have been much annoyed by this pest…The absence of greater locker space make[s] it difficult for the patients to keep the rooms and wards neat and also makes it difficult to keep the buildings as clean as might be desired. It is also a question whether with a full complement of patients the bathing and washing facilities are going to be adequate."

Though improvements were made to both sets of pavilions within the first few years of their construction, including the addition of cabinets to the men's and women's buildings at Piedmont, and screening for both Piedmont and Blue Ridge, the pavilions were never embraced as great successes.

The campaign for additional facilities that followed the construction of the pavilions engendered a denigration of the early structures. Beginning in 1935, Board minutes reflect a growing intolerance for their inadequacies:
"…the greatest number of buildings possible were erected with the limited funds at our disposal. The buildings were very temporary in character, being built of common pine lumber, with lath stucco walls and paper composition roof. Toilet and bath facilities on these buildings have always been inadequate, there being four toilets, two tubs and two showers for thirty-eight patients...The condition of these buildings is not at all good; many of the timbers are rotting and becoming weak, and something will have to be done for their replacement in the near future."

Thereafter, complaints show up consistently in the Board minutes varying from "It taxes our facilities to the utmost to try to take care of these infirmary type patients on buildings that were not designed for ill patients," to "It is getting increasingly difficult to maintain these buildings in proper condition to take care of patients, and I hope that we may be able to get an appropriation by the next General Assembly to replace them with a modern fire-proof infirmary."

The successful campaign for improved facilities resulted in the opening of a new infirmary two years later in 1939, hastening the demise of the pavilions despite initial accommodation of them by moving the Addison pavilion in front of the Thomas pavilion. (Fig 18) The Strode pavilion was closed the winter that the infirmary opened and upon reopening, only the west wing received patients "on account of the poor condition of this [the east] portion of the structure. The sills and floor joists being rotten, the lower ends of the studding being decayed and the walls bulging…" The final blow came with the annex to the infirmary building, erected in 1949, intended from inception to replace at least two of the pavilions which were "not fire-proof," because it was "highly probable that a heavy snow may crush them or a severe windstorm cause them to collapse." In 1950, patients remaining on the Addison and Thomas pavilions were transferred to the new West Wing of the Infirmary. Those on the Strode were transferred to the Trinkle building in 1951, and shortly thereafter the three pavilions were razed. In its account of the final years of the Blue Ridge pavilions, the Annual Report of that year stresses:

"These buildings…were temporarily constructed, and were expected to last for a period of only ten to twenty years…For a period of a year or more before vacating these…buildings the patients had complained almost continuously about the discomfort they were having to undergo from the poor condition of the buildings, and the exposure they were having to undergo in cold, rainy, bad weather."

Unimpeded by the old wooden structures, the gleaming modern architecture of the new hospital dominated the Sanatorium landscape.

The drive for additional facilities, augmented by uncomplimentary reflections on the pavilions, was motivated by more than a need for additional space; it was driven by changing perceptions of the treatment of tuberculosis. The transition from the one story wooden pavilions to the multi-leveled brick infirmary mirrors the shift in medical theory from a homeopathic approach of rest, fresh air, and a healthy diet, to one of surgery and antibiotics. As articulated by Superintendent and Medical Director at Blue Ridge, Dr. W.E. Brown, in 1942, "The need for the construction of new buildings is self evident…The new and highly efficient surgical collapse treatment for this disease is enabling us to benefit many patients who were formerly considered hopeless, but in order to take care of such cases sufficient hospital beds must be available." "Sufficient" here refers not to number of beds, but to the quality of their situation. That is, not on the pavilions. As the treatment of tuberculosis grew increasingly scientific with the adoption of artificial pneumothorax, most popular in the 1930s, and antibiotics, introduced in 1944, additions to the sanatorium landscape adopted more permanent materials, shed the rustic aesthetic of overhanging eaves, enclosed what had been open, and abandoned any relationship with the land, as they rose in height. (Fig 19)

However, this transition was a gradual one and its development is evident in the buildings constructed in the years between the earliest construction and the final phases of the program. At Blue Ridge, the Trinkle and the Wright buildings retained the general footprint of the pavilions, a central core with flanking wings, though they rose in height. (Fig 20) Both incorporated screened porches, southern exposures, and overhanging eaves, as did the Garret building. (Fig 21, Fig 22, Fig 23) A detachment from the early designs began with the enclosure of the porches on the Wright building. Architecturally expressing the gain in popularity among physicians of pneumothorax and antibiotics, the brick infirmary and annex presented a more official façade and encased spaces previously open, deliberately distancing patients from the landscape, which was no longer valued for its healing potential. (Fig 19) The razing of the pavilions at Piedmont and Blue Ridge in the early 1950s signified a break from the past and initiated the institutionalization of disease familiar today.

Though gradually phased out of the sanatorium landscape as advancements in treatment rendered them obsolete, the patient pavilions and the fresh air living they promoted thrived in the domestic landscape. The adoption of the sleeping porch and its progression from an addition to full integration into design reveals the widespread acceptance of associating fresh air with good health. Promotional literature boomed in the early years of the century and continued disseminating its message into the 1930s. Advertising the benefits of sleeping outdoors, Country Life in America informs:

"The man who wakes up cross and never eats breakfast, becomes good natured and hungry in spite of himself. The woman who has come to regard her nervous headache almost as a part of herself, and the youngster whose winters have been closely associated with hot lemonades and mustard baths, find that headaches and colds can't stand oxygenation."

Publications including Making and Furnishing Outdoor Rooms and Porches (1912), Planning for Sunshine and Fresh Air (1931) and articles like "Sleeping with air" (1914) promoted the extension of the boundaries of the house into the outdoors. Marketing to a public conversant in the architectural expression of healthy living, the Sears, Roebuck Modern Homes catalogue included "The Saranac," from 1917-1922 among its small cottage designs. (Fig 24)

That this vocabulary was embraced so enthusiastically by the public reveals a universal familiarity with tuberculosis and its treatment, due in part to the educational campaigns of Boards of Health across the country. The phenomenon of the addition of the sleeping porch to domestic architecture was considered a great success among members of the Boards of Health. It signified that the efforts to educate the public about tuberculosis had proved fruitful. Indeed, education was as much a part of the fight against tuberculosis as the cure. Arguing that multiple tuberculosis institutions would spread the education of healthy living further than a single larger institution, a letter to the State Board of Health recorded in the minutes of the annual meeting of 1918 emphasized this mission: "The value of the sanatorium i[s] education of the general public…The sleeping porch of the modern private residence; the open-air schools; the constantly increasing number of open windows in our factories have been chiefly prompted by the demonstration of our sanatoria." This sentiment was echoed in 1923:

"Is the cost of treatment of pulmonary tuberculosis justified? I should say that if our sole results were the number of cases cured of pulmonary tuberculosis that institutions are not justified. In my opinion the greatest result obtained is the training and instructions in public health that is gotten by these tubercular people and disseminated among their home people. The growing popularity of the sleeping porch is a result of sanatorium treatment."

Evidenced in the accommodation of sleeping porches into the design of their own staff and administration buildings at Piedmont and Blue Ridge, education by example was integral to sanatorium design. (Fig 25)

There would not have been any question in 1917 and 1919, when the first patient pavilions went up at Piedmont and Blue Ridge Santorias, of what type of institution was taking shape. Just as ubiquity of form makes a high school or shopping mall readily identifiable today, so too would the prevalent southern facing, open pavilion have signified a tuberculosis sanatorium during the early decades of the twentieth century. Central to "the cure," the plans, details, and settings of these pavilions capture key elements of the early tuberculosis treatment in this country. Their noticeable absence from their former sites today is equally illustrative of the turning point in the treatment of the disease. While no longer standing, the formal elements of these pavilions are not entirely lost. Careful examination of the buildings that supplemented and eventually replaced the pavilions reveals a dialogue between the structures. However, despite the persistence of formal characteristics, the camping out qualities of the early pavilions were entirely abandoned as the building program advanced. Ironically, the ideals contributing to the design of patient pavilions contributed also to their demise almost from the beginning, as the rustic summer architecture on which they were modeled could not sustain year round use. Yet, while the pavilions were gradually phased out and eventually removed from the sanatorium landscape altogether, their influence reached well beyond the sanatorium into the realm of domestic architecture in the form of the sleeping porch. Ambassadors of healthy living, the pavilions initiated an affair with outdoor living that continues to influence design today.

Works Cited
Brimmer, F.E. Cabins, Lodges, and Clubhouses. (New York: D. Appleton and Company, 1925).

Carrington, Thomas Spees. Tuberculosis Hospital and Sanatorium Construction. (New York, 1911, 1914)

D'Enville, "Sleeping Outdoors for Health," Country Life in America v.16 (May 1909): 43-46+

Eberlein, Harold Donaldson. Making and Furnishing Outdoor Rooms and Porches. (New York: McBride, Nast & company, 1913).

Hooper, Charles Edward. "Sleeping with Air," Country Life in America v.26 (May 1914), 58-59.

Hopkins, Alfred. Planning for Sunshine and Fresh Air. (New York: Architectural Book Publishing Co., Inc., 1931).

Northend, Mary Harrod. The Small House, its Possibilities. (New York: Dodd, Mead and Company, 1923).

Ott, Katerine. Fevered Lives. (Cambridge: Harvard University Press, 1996)

Rothman, Sheila. Living in the Shadow of Death. (New York: Basic Books, 1994).

Stevenson, Katherine Cole and H. Ward Jandl. Houses by Mail: A Guide to Houses from Sears, Roebuck and Company. (Washington, D.C.: The Preservation Press, 1986).

Unpublished Documents

Health Sciences Special Collections, University of Virginia:
American Lung Association of Virginia, Boxes 90, 158, 159.
Blue Ridge Sanatorium, Box 6

Library of Virginia:
Annual Reports of the State Board of Health, 1917, 1923
Minutes of the State Board of Health of Virginia 1908-1918
Minutes of the State Board of Health of Virginia 1919-1924
Virginia Health Bulletin, vol. 2 no. 3 (March, 1910)

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