Cover of an informational pamphlet with library marks.

Patient Pamphlet for Piedmont TB Sanatorium, VA, 1940

Circulating Now welcomes guest bloggers Kiana Wilkerson, Katherine Randall, PhD, and E. Thomas Ewing, PhD to share their research on the Piedmont Tuberculosis Sanatorium for the treatment of African American patients in Virginia. Learn more about their History of Catawba and Piedmont Tuberculosis Sanatoria project and explore source materials on the project website.

A page from a pamphlet headed General Information.
Rules and Information for Patients: Piedmont Sanatorium, 1940
National Library of Medicine #101573062

“Why should I go to a sanatorium to ‘Take the Cure’?” was the first question posed in the Rules and Information for Patients published by the Piedmont Sanatorium. This short booklet, formatted as an extensive FAQ, served to inform new and prospective patients about the goals, policies, and logistics of “taking the cure” at the facility. The answers illustrate both the contemporary medical science on the best treatment for tuberculosis and broader cultural perceptions of tuberculosis patients. The Rules thus offers a unique perspective on the medical purpose of tuberculosis sanatoria in twentieth century America. The Piedmont Rules are also distinctive, however, because this institution offered treatment only to African American patients

Piedmont Sanatorium was established in 1918, one decade after Catawba Sanatorium was established as the first state institution to treat this disease in Virginia. Both Catawba and Blue Ridge (opened in 1918) were exclusively for white patients while Piedmont was created to treat African Americans, who had much higher rates of infection, serious conditions, and deaths associated with this disease. By 1940, these three sanatoria were the only institutions providing full time tuberculosis treatment, along with municipal sanatoria offering more limited treatment. In the 1940s, and nearly 500 African American patients a year were receiving treatment at Piedmont Sanatorium.

Chart showing that the deaths for African Americans was consistantly almost three times higher than for whites although both decreased steadily over 30 years.Treatment

The answer to the question cited above provides insights into the purpose and functioning of tuberculosis sanatoria in the twentieth century. According to the Rules, treatment for this disease required a complete change in conditions, behavior, and expectations:

“In order to get well with tuberculosis it will be necessary that for some months you change entirely your whole manner of living. You will have to give up your work and your play, and take rest.”

The advantage of entering a Sanatorium is being surrounded by people who look well yet are taking the cure, creating a social environment where a rest cure is normalized; thus, “…what is immensely hard to do at home becomes quite easy at the Sanatorium.” Patients were encouraged to remember that “…the sooner you give up and get in bed when you find you have tuberculosis the quicker you will get out. The longer you put it off the longer you will be there.”

The Rules began with an affirmative answer to the question, “Is tuberculosis curable?” with a statement that combined medical conditions and mental outlook: “Given an early case in an intelligent individual and there is no serious disease more easily curable than tuberculosis; even advanced disease can be arrested, but it requires prolonged effort and the foolhardy soon succumb.” This cure was “rather difficult” to accomplish in six months, yet this limit was placed to make room for others, allowing the sanatorium to accomplish “the greatest good…for the greatest number.”

The Rules made clear that the purpose of tuberculosis sanatoria was to treat early cases deemed curable, with only limited facilities available to those with more serious conditions or living situations that required isolation from family and community members.

Race and Health

The Rules mentioned race only one time, in reference to a question about eligibility: “This is a State Institution and only bona fide colored citizens of Virginia suffering from uncomplicated tuberculosis of the lungs are eligible.” This statement mirrored the similar statement in the Rules and Information for Patients for Catawba sanatorium, which specified that “only bona fide white citizens of Virginia are eligible for admission and treatment.”

Detail from a page with questions including: "Who is eligible?"
Rules and Information for Patients: Piedmont Sanatorium, 1940
National Library of Medicine #101573062

The Rules for Piedmont Sanatorium never acknowledged the fact that this institute was part of a rigidly segregated public health system in Virginia other than the statement about eligibility. While the Rules for Piedmont and Catawba indicate little difference between the institutions, and Virginia State Health Department statistics for 1920, 1930, and 1940 demonstrate that the death rate per 100,000 for whites and non-whites (mostly African Americans) had declined significantly across the board, still, more than twenty years after Piedmont opened in 1918, the death rate for African Americans in 1940 was almost 30% higher than the rate for whites had been in 1920. The Rules may have implied that race was not a factor, but our study of the Piedmont community reveals important ways that race shaped the history of tuberculosis treatment in segregated Virginia.

Daily Schedule

Page from a pamphlet with headings related to rules for patients and a daily schedule.
Rules and Information for Patients: Piedmont Sanatorium, 1940
National Library of Medicine #101573062

A “daily schedule” emphasized the priority assigned to rest in the treatment regime, with “rest in bed” scheduled for more than three hours every morning and every afternoon. While exercise “ordered by the physician” were allowed in the morning and later afternoon, more than two hours every afternoon was designated as “Quiet Hour,” with this explicit requirement: “Rest in bed, no talking or visiting allowed.”

While exercise was designated as a necessary part of treatment, the limits were made clear: no exercise in the first two weeks after admission, exercise allowed only for patients with low temperature and pulse rates, and exercise was limited “to walking or some simple task given by the doctor and under the directions of a trained assistant.” Patients were not allowed to spend more time exercising than the physician prescribed: “If you have fifteen minutes exercise twice daily, take that amount and remain in bed the remainder of the day.”

Rules for daily life included detailed explanations of personal hygiene and steps that must be taken to preserve health. More than two pages were devoted to coughing and expectorating, beginning with this advice: “Never cough when you can avoid it… Learn to cough with your mouth closed.” Cheese cloth was available to all patients, to cover their mouth and nose when coughing, sneezing, or clearing the throat. After use, the cheese cloth should be folded carefully and placed in a bag, “otherwise you may reinfect yourself and others.”

Illustrating how measures intended to reduce infection were combined with efforts to reduce anxiety, patients who expectorated “blood-stained sputum,” which would signify a deterioration in health conditions, were told to “stay quietly on bed and have some one notify nurse.” The Rules also prohibited interactions that might further anxiety about the disease: “Conversation about patients about their diseases, symptoms, or any subject relating thereto, is forbidden during meals, and is discouraged at all times. It never does good, but often does much harm.”

The Serious Business of Getting Well

Piedmont Sanatorium offered treatment to men and women, yet the Rules demonstrated concerns about interactions among the sexes. During exercise, men walked on the east side of the building and women walked on the west side. An answer to a question about separating men and women illustrated how medical treatment intersected with moral concerns: “You are here for the serious business of getting well. Flirtations are harmful to the sick. If you are not interested in flirtations then this rule does not affect you.” A later section of the Rules on “Association of patients of opposite sex” reinforced these guidelines, with text in bold to emphasize the main point:

“The association of patients of opposite sex is not permitted. Flirtations are not permitted, and when any two patients of opposite sexes seem to be associated together very frequently their attention will be called to same; should the intimacy continue after this warning both parties will be subject to dismissal.”

Cover of an informational pamphlet with library marks.
Rules and Information for Patients: Piedmont Sanatorium, 1940
National Library of Medicine #101573062

The Rules included a strong moral code: no gambling or games of chance, no practical jokes, no use of alcohol unless prescribed by a physician, and no use of tobacco except by special permission from the Superintendent to smoke after meals on the front porch. High expectations for individual behavior extended beyond treatment at the facility. Patients who left the sanatorium “against advice” before completing treatment would not be admitted again, with this moralizing explanation: “It is our experience that it is useless to waste time with the headstrong and ignorant. It is impossible to treat tuberculosis without the full cooperation of the patient.”


These rules were outlines of prescribed behavior. Historians who have examined diaries or letters from other sanatoria have found ample evidence that actual behavior, interactions, and attitudes could diverge quite widely from the written rules and unwritten assumptions of these regulations and rules. As we uncover more information about patients and staff at Piedmont Sanatorium, we hope to reveal the complexities of the stories of the men and women whose lives in this institute were certainly more complicated than the Rules would indicate.

A casual portrait of a young black woman outdoors.Kiana Wilkerson is a 2018 graduate from the College of William and Mary, where she received a BA in History and Anthropology. She is currently pursuing a MA in History with a certificate in public history at Virginia Tech. Her research interests include 20th-century African American history and representation specifically in comic books.

A casual portrait of a white woman outdoors.Katherine Randall is a Visiting Lecturer in Technical Communication at the University of Central Florida. Her research focuses on medical rhetoric and health communication. In 2018, she and Dr. Ewing co-edited Viral Networks: Connecting Digital Humanities and Medical History, which grew out of an interdisciplinary workshop hosted by the History of Medicine Division of the National Library of Medicine. @katierandall

Casual portrait of a white man outside.E. Thomas Ewing is a professor of history at Virginia Tech, with research interests in the history of influenza epidemics. In 2018, he directed a summer workshop on the 1918 influenza epidemic funded by the National Endowment for the Humanities in partnership with the History of Medicine Division, National Library of Medicine. @ethomasewing


  1. The TB hospital info is of great interest. My own institution started on the site of a WWII Army camp hospital, was acquired by state, and became a TB sanatorium in the late 1940’s. We have considerable archives on that, including a letter from a judge to a patient at another Texas sanatorium that outlined what needed to brought along for admission. My institution still has a legislative mandate as the primary state facility for lung diseases, but inpatient TB care is carried out at another hospital now whose physicians report to a supervisor here. On a closer-to-home note, my grandfather died of TB here in 1954 in one of the barracks-type wards used by the Army.

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