2008 Architecture and Tuberculosis

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Collapse and Expand: Architecture and Tuberculosis Therapy in Montreal,

1909, 1933, 1954
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Architecture and Tuberculosis Therapy in Montreal,
1909, 1933, 1954
ANNMARIE ADAMS, KEVIN SCHWARTZMAN,

a n d D AV I D T H E O D O R E
During the mid-twentieth century, Montreal’s Royal Edward Laurentian

Hospital (now known as the Montreal Chest Institute) enjoyed a reputation
as the major tuberculosis referral hospital in Canada’s largest city (fig. 1).
Montreal’s notoriety in the campaign against the disease came from having
one of the highest mortality rates of large North American cities.1 An im-
portant center for innovative medical research and training, Montreal was
the site of pioneering developments in tuberculosis surgery, while at the
same time maintaining strong links with the sanatorium movement.
Montreal surgeon Edward Archibald, for instance, performed the first tho-
racoplasty in North America in 1911 at the Royal Edward’s sister institu-
tion, the Royal Victoria Hospital. Outspoken surgeon, inventor of modern
surgical instruments, and tuberculosis activist Norman Bethune called
Montreal his home from 1929 to 1936.2
Annmarie Adams is William C. Macdonald Professor of Architecture at McGill Univer-

sity. Kevin Schwartzman is a researcher with the Respiratory Epidemiology and Clinical
Research Unit at the Montreal Chest Institute (MCI) and Associate Professor of Medi-
cine at McGill University. He is the recipient of a Chercheur-Boursier Clinician career
award from the FRSQ (Fonds de la recherche en santé du Québec). David Theodore is a
research associate in the School of Architecture at McGill University. The authors thank
Valerie Minnett, Mary Phung, Mary Anne Poutanen, and Jan Schotte for helping with
this research, and Thomas Schlich for reading an earlier version of this paper. The au-
thors’ larger project is funded by the Social Sciences and Humanities Research Council
of Canada. Architecture student Peter Sealy gathered general information on the history
of the MCI under the supervision of the authors through the auspices of an FRSQ un-
dergraduate research grant titled “Constructed Medicine: The Treatment of Tuberculo-
sis at the Montreal Chest Hospital,” submitted 27 August 2003.
©2008 by the Society for the History of Technology. All rights reserved.
0040-165X/08/4904-0004/908–42
1. See Terry Copp, The Anatomy of Poverty: The Condition of the Working Class in
Montreal, 1897–1929 (Toronto, 1974), 100–102.
2. Edward Archibald, “The Development of Surgical Methods in Treatment,” in The
908
ADAMS et al.K|KArchitecture and Tuberculosis Therapy in Montreal
FIG. 1 Royal Edward Laurentian Hospital (Montreal division), shortly after the
1957 expansion that added three floors to the surgical towers. (Reproduced
courtesy of the Montreal Chest Institute.)
Studying the Royal Edward’s history allows us to juxtapose medical and

architectural expertise and technologies. Two ritual ribbon-cutting cere-
monies illustrate this intersection. The 1909 opening of the first Royal Ed-
ward Institute on Belmont Park, a renovated house, showcased technolog-
ical prowess. King Edward presided over the opening remotely from
England. A transatlantic telegraph (fig. 2) sent from his library in Col-
chester caused the lights in the hospital that bore his name to illuminate,
the door to swing open, and a flag to ascend.3 “We do not know that any
Imperial episode has made a finer appeal to the imagination,” remarked the
London Observer.4
Forty-five years later, the institute’s surgical and laboratory building
opened with a very different presentation of technological know-how.
Story of Clinical Pulmonary Tuberculosis, ed. Lawrason Brown (Baltimore, 1941), 281–
323. On Archibald, see Lloyd D. MacLean and Martin A. Entin, “Norman Bethune and
Edward Archibald: Sung and Unsung Heroes,” Annals of Thoracic Surgery 70 (2000):
1746–52.
3. “Tuberculosis Institute,” Gazette, 21 October 1909, 1, 6. The best technical descrip-
tion is “Royal Edward Opened by King,” Gazette, 22 October 1909, 7. See also “King’s
Hand Opens Doors of New Home,” Montreal Daily Star, 21 October 1909, 7.
4. London Observer, 24 October 1909, quoted in Royal Edward Chest Hospital, Sixty
Years into the Future (Montreal, 1969).
909
T E C H N O L O G Y A N D C U LT U R E
OCTOBER
2008
VOL. 49
FIG. 2 Telegraph switch wired to open doors with a transatlantic signal at

the Royal Edward Institute, 1909. (Reproduced courtesy of the Montreal
Chest Institute.)
Whereas in 1909 the opening was an international social occasion with a

climax of nonmedical, technological pomp, the 1954 opening showcased
medical knowledge in a deliberately stark container—the hospital. News-
paper coverage highlighted the public interiors of the hospital, especially its
modern lecture hall and entry lobby, rather than spaces for patients or sur-
gery. Tuberculosis experts from across North America arrived in Montreal
for a symposium to discuss current approaches to the disease. The transat-
lantic remote-response spectacle of 1909, celebrating philanthropy and
charity, was thus displaced by an in-person ceremony that showcased med-
ical knowledge and research. Attendees of the 1954 opening swapped
patient statistics and diagnostic techniques in an atmosphere of both com-
petition and collegiality, like an academic conference today. Royal repre-
sentation, however, was still important: Vincent Massey, governor general
of Canada, toured the building on 15 April 1955. The sharp change and
subtle overlap in emphasis in these two opening events nearly five decades
apart is a lucid indicator of both the continuous cultural value of tubercu-
losis therapy and the rapid rate of change in tuberculosis technologies.
This article examines the complex history of an urban, specialized hos-
pital as a way to explore the relationship of medicine and architecture, the
disciplinary backgrounds of the three co-authors. Our combined perspec-
tives, we think, shed new light on how buildings serve as medical technolo-
910
gies and, conversely, on how technology adjusts and adapts to different

architectural settings. Our innovative methodology posits hospital archi-
tecture as a form of medical technology, a position rarely adopted by histo-
rians of technology and medicine, who tend instead to imagine buildings
as neutral, nontechnological settings for smaller-scale artifacts. Even schol-
ars who insist on the social construction of medical technology typically
overlook the role of the hospital building itself.5 Moreover, using the his-
tory of medicine to investigate hospital architecture as a technology allows
us to study the Royal Edward as a cultural landscape. This approach, a sub-
field of mainstream architectural history, emphasizes the need to engage
places over an extended lifecycle and to substantiate how the context, use,
and experience of buildings contribute to architectural meaning.6
Approaching hospital environments as cultural landscapes requires en-
gagement with an extraordinarily wide range of primary sources. These in-
clude traditional, architect-produced documents like measured drawings,
photographs (construction and interiors), building specifications, zoning
diagrams, and professional correspondence, as well as sources commonly
used by scholars studying vernacular architecture: amateur photography and
ephemera like posters and postcards. Juxtaposing this visual evidence with
sources in the history of medicine, such as annual reports, medical textbooks,
journal articles, doctors’ correspondence, conference proceedings, statistics
regarding the spread of tuberculosis, patient records, the personal reminis-
cences of physicians and nurses, and medical technologies, we believe, pro-
vides a new and nuanced look at spatial responses to disease. What role has
architecture, as a technology, played in the fight against tuberculosis?
The Technologies of Tuberculosis Therapy
Our aim is to understand how new technologies overlap, displace, and

parallel existing ones. More specifically, we look at the relationships be-
tween twentieth-century technologies associated with the care and treat-
5. Scholars of medical technology rarely discuss the hospital itself as a technology.

See, for example, Pascale Lehoux, The Problem of Health Technology: Implications for
Modern Health Care Systems (New York, 2006), and Joel D. Howell, Technology in the
Hospital: Transforming Patient Care in the Early Twentieth Century (Baltimore, 1995). An
exception is Peter Keating and Alberto Cambrosio, Biomedical Platforms: Realigning the
Normal and the Pathological in Late-Twentieth-Century Medicine (Cambridge, Mass.,
2003).
6. Dell Upton, Architecture in the United States (Oxford, 1998), 12. On understand-
ing architecture as cultural landscape, see Upton, “Architectural History or Landscape
History?” Journal of Architectural Education 44, no. 4 (1991): 195–99; “The Power of
Things: Recent Studies in American Vernacular Architecture,” American Quarterly 35, no.
3 (1983): 262–79; Paul Groth and Chris Wilson, eds., Everyday America: J. B. Jackson and
Recent Cultural Landscape Studies (Berkeley, Calif., 2003); and Todd Bressi and Paul
Groth, eds., Understanding Ordinary Landscapes (New Haven, Conn., 1997).
911
ment of tuberculosis: the fresh-air cure, collapse therapy, surgical therapy,

chemotherapy, and hospital architecture.7 Tuberculosis technologies—in
this sense, sets of resource-using practices marshaled to eradicate the dis-
ease—did not efficiently replace each other (one by one) in response to
medical innovation; but neither did contradictory tuberculosis technolo-
gies simply co-exist as an aggregate of possible alternatives. Rather, the
OCTOBER
technologies developed in a complex, dynamic interaction with one
2008 another and within their cultural landscapes. Indeed, seemingly outdated
VOL. 49
technology often survived, providing underlying continuity, as newer ones
induced major changes to the overall interplay of hospital organization,
medical care, and social doctrine.8
Our argument that architecture serves as a medical technology is in-
spired by a remarkable line in the 1949 Montreal Star suggesting the inter-
changeability of architecture and drugs. Explaining how streptomycin, an
expensive medicine, would be given at no cost to tuberculosis patients in
Quebec, a journalist wrote that the “costs of the drug will be charged
against the $1,069,564 allotted to Quebec in 1948–49 for the extension of
tuberculosis control facilities.” 9 Engaging contemporary textual sources
like these, we argue that architecture is more than the background context
for these medical debates: it is itself one of the technological alternatives
whose role reciprocally destabilizes and shapes the others.10 The rest cure
for tuberculosis prevalent at the beginning of the twentieth century started
a tradition, lasting until the age of antibiotics, where architecture (or more
generally the patient’s immediate environment) served explicitly as an ac-
tive physical agent in tuberculosis treatment.11 Tuberculosis architecture,
7. Other tuberculosis therapies included such “quack” remedies as gold treatment,

inhalations, and exposing patients to X-rays; see Thomas Dormandy, The White Death:
A History of Tuberculosis (New York, 1999), 273–83. Linda Bryder emphasizes the impor-
tance of prevention also: “isolation of tuberculous patients, preventing people with
tuberculosis from working in food trades, the control of milk supplies, vaccination [BCG
(Bacillus Calmette-Guérin) vaccine], education, the provision of open-air schools, and
the boarding out of susceptible children”; see Bryder, Below the Magic Mountain: A Social
History of Tuberculosis in Twentieth-Century Britain (Oxford, 1988), 130–56.
8. For a similar argument about the engagement of experimental physics and every-
day life, see Peter Galison, Image and Logic: A Material Culture of Microphysics (Chicago,
1997), 46–63.
9. James A. Oastler, “Streptomycin To Be Given Free To Quebec T.B. Patients,”
Montreal Daily Star, 10 February 1949, 1.
10. On technology and culture as mutually constitutive, see Lehoux, xiii.
11. On the history of the rest cure, see Frank Ryan, The Forgotten Plague: How the
Battle against Tuberculosis Was Won and Lost (Boston, 1993); R. Y. Keers, Pulmonary
Tuberculosis: A Journey Down the Centuries (London, 1978); and Dormandy. The history
of tuberculosis therapy was often recounted during the time period under study; see
P. D. Hart, “Chemotherapy of Tuberculosis: Research during the Past 100 Years,” British
Medical Journal 2 (1946): 805–10, 849–55; G. M. Balboni, “The Development in the
Treatment of Pulmonary Tuberculosis from 1696 to the Present Time,” New England
Journal of Medicine 212 (1935): 1020–27; and Brown (n. 2 above).
912
first with its “low-tech” porches, balconies, sunning galleries, and occupied
rooftops, then later juxtaposed with “high-tech” operating rooms and sur-
gical suites, provided crucial physical and spatial stability. This architecture
proved a lasting symbolic presence for physicians, surgeons, public health
officials, and patients—even after the successes of chemotherapy, the first
therapy to directly and specifically target the tubercle bacillus, augured the
end of specialized tuberculosis-treatment settings.
Perhaps our most unexpected finding is that the architecture of the Roy-
al Edward expresses in spatial terms a hesitation or even pessimism about
the importance and efficacy of antibiotics—surprising because retrospec-
tively, the introduction of drug therapy at the close of World War II made a
dramatic break with established traditions. By the 1960s, antimicrobial
treatment had rendered sanatoria, the rest cure, and collapse therapy obso-
lete in North America.12 Tuberculosis deaths in Canada dropped from 7,698
in 1921 to 1,403 in 1955 (in Quebec from 2,909 to 608).13 Likewise, tuber-
culosis mortality rates decreased from 87.7 (per 100,000) in 1921 to only 8.9
in 1955 (from 123.2 to 13.5 in Quebec).14 The progressive decline in tuber-
culosis morbidity and mortality continued through the late 1980s. How
much did this discrepancy between design and practice, the overlapping
though distinct histories of architectural modernization and scientific inno-
vation, reflect differences of opinion between surgeons and nonsurgeon
physicians about tuberculosis care?
This article scrutinizes the architectural and medical evidence for the
interplay of design with established and new therapies in three historical
moments: 1909, 1933, and 1954. Overall, our story is straightforward. The
increasing use of collapse therapies—beginning with pneumothorax (the
injection of air into the pleural cavity to collapse the lung inward), followed
by more aggressive thoracoplasties (surgical removal of ribs to produce col-
lapse of the chest wall and underlying lung tissue), and finally surgical
resection of the diseased lung—did not displace the material culture of the
rest cure. Instead, the established architectural setting expanded to include
spaces for surgery.15 Conversely, the surgical interventions were in one
sense continuous with earlier ideas about rest as an aspect of tuberculosis
stabilization and cure, but here applied locally to diseased lung tissue: sur-
gical removal was a way of permanently “resting” affected lung tissue.
12. Katherine McCuaig questions the efficacy of medical intervention in the fight
against tuberculosis; see McCuaig, The Weariness, the Fever, and the Fret: The Campaign
against Tuberculosis in Canada, 1900–1950 (Montreal, 1999), 3–8. In Below the Magic
Mountain, Bryder states that there is “no evidence that collapse therapy had any effect on
the course of the disease” (p. 259).
13. From George J. Wherrett, The Miracle of the Empty Beds: A History of Tuberculosis
in Canada (Toronto, 1977), quoted in McCuaig, p. 291, table A13.
14. Ibid., p. 292, table A14.
15. For a contemporary illustrated survey of collapse techniques, see John Alexan-
der, The Collapse Theory of Pulmonary Tuberculosis (Springfield, Ill., 1937).
913
Tuberculosis History
In the timeframe under study, the role of technology is vital to under-

standing tuberculosis history because of the complicated entanglement of
therapy, medicine, prevention, and social conceptions. We follow medical
historian Joel Howell’s definition of “technology” as including physical arti-
OCTOBER
facts, goal-oriented activities, and social knowledge.16 Studying tuberculo-
2008 sis technology through the interplay of architecture and therapy is espe-
VOL. 49
cially germane because of the sanatorium movement. In 1854, Swiss
physician Hermann Brehmer instituted a program of fresh air and rest in a
settlement at Göbersdorf in the Alps, a romantic, mountainous terrain.17
Edward Trudeau imported the sanatorium idea to the United States at Sara-
nac Lake in New York.18 Canada’s National Sanitarium [sic] Association
formed in 1896 and opened its first sanatorium at Muskoka, Ontario,
ninety kilometers north of Toronto, in 1897.19 Sanatoria were intertwined
with the clean, linear, functionalist buildings associated with modern archi-
tecture, especially in Europe. Celebrated European sanatoria include those
by well-known architects such as Alvar Aalto at Paimio, Finland, Johannes
Duiker at Hilversum, the Netherlands, and Otto Wagner and Josef Hoff-
man near Vienna. Such buildings, especially at Paimio, attracted attention
because pioneering architectural historians such as Sigfried Giedion used
the clean, white, undecorated architecture of the modern hospital to ex-
plain what they understood as the relationship of form and function: that
the distinct parts and functions of a building are integrated into a bold,
pure conceptual whole, like the organs within the body.20 The architects
whose mission it was to effect social change (to cure the sick) exploited
modern materials and construction techniques, just as they did in the arch-
itecture of social housing, the centerpiece of European international-style
16. Howell, Technology in the Hospital (n. 5 above), 8–9. Howell’s work is significant
for us because he aims to “make it clear what choices were available to those who wished
to use new technology without assuming that the choices that were made were somehow
natural or inevitable” (p. 11).
17. Brehmer believed that tuberculosis patients had weak hearts that could be aided
by the low pressures at high altitudes; see Dormandy (n. 7 above), 150–53. By 1911, there
were important how-to books on sanatorium architecture, such as Thomas Spees Car-
rington’s Tuberculosis Hospital and Sanatorium Construction (New York, 1911).
18. On Trudeau and medical life at Saranac Lake, see David L. Ellison, Healing
Tuberculosis in the Woods: Medicine and Science at the End of the Nineteenth Century
(Westport, Conn., 1994).
19. On the architectural history of the Muskoka sanatorium, see Annmarie Adams
and Stacie Burke, “‘Not a shack in the woods’: Architecture for Tuberculosis in Muskoka
and Toronto,” Canadian Bulletin of Medical History 23, no. 2 (2006): 429–55. Sanatorium
ideals also extended to home situations, as illustrated in Thomas Spees Carrington, Fresh
Air and How to Use It (New York, 1912).
20. See Sigfried Giedion, Space, Time, and Architecture: The Growth of a New Tradi-
tion, 5th ed. (Cambridge, Mass., 1967), 629–32.
914
modernism.21 Architects specified expansive areas of glass in order to max-

imize sunlight and views; structural steel frames meant that building plans
could be open and thus more flexible than ever before. The absence of inte-
rior, structural supports also meant that fresh air could more easily circu-
late between the functional zones of hospitals. Nevertheless, because tuber-
culosis was highly contagious, even institutions that showcased modern
architecture, such as Aalto’s hospital at Paimio, included separate rooms for
patients.
By 1909, bacteriological research had firmly attached the disease to a
single agent—a bacterium—and the scientificization of tuberculosis treat-
ment was well under way: doctors, if not the general public, believed indi-
viduals caught the disease because of a germ, rather than because of a
moral failing or through heredity.22 German physician Robert Koch iso-
lated the rod-shaped tubercle bacillus (Mycobacterium tuberculosis) in
1882. Tuberculosis was diagnosed using technologies such as chest X-rays,
tuberculin tests, and microbiologic cultures of sputum—which reciprocally
emphasized the presence of science.23 In 1926, for instance, the Royal Ed-
ward Annual Report states: “Sputum from 392 [patients] was examined and
positive results were obtained in 56% of those diagnosed tubercular.”
Nevertheless, tuberculosis remained overwhelmingly a social problem
precisely because there was no effective, scientifically established medical
therapy.24 Clearly, prevailing cultural and lay beliefs about modern medical
care inspired and conditioned the adoption of leading-edge therapeutic ad-
vances. Tuberculosis had been linked to poverty and poor living conditions,
and thus it was a privileged vehicle for private and state reformers, philan-
thropists, public health professionals, and educators, a conglomeration of
players often categorized as the “anti-tuberculosis movement.” For our
story, a crucial manifestation of the antituberculosis movement is the 1908
Montreal Tuberculosis Exhibition, which targeted the home as the main
vehicle of disease transmission. The exhibition’s design urged visitors to
21. See Margaret Campbell, “What Tuberculosis Did for Modernism: The Influence
of a Curative Environment on Modernist Design and Architecture,” Medical History 49
(2005): 463–88; Leslie Topp, “An Architecture for Modern Nerves: Josef Hoffmann’s Pur-
kersdorf Sanatorium,” Journal of the Society of Architectural Historians 56, no. 4 (1997):
414–37; “Otto Wagner and the Steinhof Psychiatric Hospital: Architecture as Misunder-
standing,” Art Bulletin 87, no. 1 (2005): 130–56; Beatriz Colomina, “The Medical Body
in Modern Architecture,” Daidalos 64 (1997): 60–71.
22. Barbara Bates, Bargaining for Life: A Social History of Tuberculosis, 1876–1938
(Philadelphia, 1992).
23. Moreover, Katherine Ott writes that the process of scientificization is material
and technological, as it entails the new notion of “apprehension of disease through the
mediation of instruments”; see Ott, Fevered Lives: Tuberculosis in American Culture since
1870 (Cambridge, Mass., 1996), 66.
24. Writing as a trained doctor during the 1990s, Frank Ryan (n. 11 above) is incred-
ulous that “the great sanatorium movement . . . with its massive utilization of public and
private funding, was never subjected to a scientific trial of its effectiveness” (p. 26).
915
transform their daily practices into action by emulating the demonstra-

tions and models presented at the exhibition and by heeding the advice of
the reformers, social gospelers, philanthropists, and health professionals.25
As historian Katherine Ott shows, the disease itself thus has a history and
can be conceived in part as a culturally produced, rather than a trans-his-
torically stable, condition.26 We argue that tuberculosis culture always
OCTOBER
includes material culture, complete with instruments derived for and from
2008 therapy and technology: inhaler, stethoscope, sputum cup, X-ray, spirome-
VOL. 49
ter—and hospital architecture.
Part 1, 1909: Establishment of the Royal Edward Institute

in Montreal
The Montreal Chest Institute began in October 1909 as a tuberculosis

dispensary in a three-story renovated house.27 The Royal Edward Institute
(fig. 3), as it was then known, was centrally located at 47 Belmont Park, a
two-block, mixed-use street near the downtown commercial core. A map in
the institution’s first annual report showed that the institute was tightly
integrated with the city’s transportation system, taking advantage of the
new electric streetcar technology (adopted by Montreal in 1892); it was a
three-to-five-minute walk from the Beaver Hall, Windsor, and St. Catherine
Street streetcar stops. Edinburgh-born financier and industrialist Sir
George Drummond was first president of the Royal Edward’s management
board. The institute had grown from the work of the Montreal League for
the Prevention of Tuberculosis (founded 1 June 1903) and housed a shelter
and a dispensary in its early years.28 Funds for the charitable clinic, “with its
25. The impact of antituberculosis thinking on Montreal home life is explored in

Valerie Minnett, “Inside and Outside: Pathology, Architecture, and the Domestic Envi-
ronment at the Montreal Tuberculosis Exhibition, 1908” (M.Arch. thesis, McGill Uni-
versity, 2004). On how notions of tuberculosis contagion affected everyday practices, see
Nancy Tomes, The Gospel of Germs: Men, Women, and the Microbe in American Life
(Cambridge, Mass., 1998), 113–34. The Annual Report of the Royal Edward Institute for
the Study, Prevention, and Cure of Tuberculosis 2 (1911) features photographs showing
“spread of TB in Montreal” that illustrate a few somewhat dilapidated streets and alleys,
but most impressively one labeled “The Cure of Tuberculosis in Montreal.” It shows a
jerry-built shack described as being twelve feet aboveground, which the caption calls the
dweller’s “private sanatorium”; it contains windows described as being adjustable de-
pending on wind direction, as well as a few basic furnishings.
26. Ott, 1.
27. On the history of the Montreal Chest Institute, see Norman C. Delarve, Thoracic
Surgery in Canada: A Story of People, Places, and Events—the Evolution of a Surgical Spec-
ialty (Toronto, 1989), 21–49; Royal Edward Chest Hospital (n. 4 above); H. E. Mac-
Dermot, A Short History of the Royal Edward Institute [presented to the] Royal Edward
Chest Convention in Honour of Hugh Edmund Burke . . . and Clarence Alexander McIntosh
. . . May 18, 1965 (Montreal, 1965).
28. E. S. Harding, “The Royal Edward Institute, Affiliated with McGill University,”
McGill News 14, no. 3 (1933): 18; Delarve, 36. The league’s work culminated in a 1908
916
FIG. 3 Royal Edward Institute (1909) on Belmont Park, Montreal, as shown in

the pre–World War I annual reports. (Reproduced courtesy of the Montreal
Chest Institute.)
bright sun parlours and large roof garden,” came from Lieutenant Colonel
Jeffrey Hale Burland (1861–1914), who also oversaw “with much judgment
and care” the alterations to the former residence.29 From March 1910 to
September 1912, 1,756 new patients sought care at the Royal Edward.30
The institute followed the “dispensary method for reaching the tuber-
culous poor”; it was an outpatient clinic only (there were no inpatient
rooms), which treated early-stage patients in their own homes and empha-
sized education.31 The dispensary model had been inaugurated in Edin-
educational exhibition on the dangers of tuberculosis, directed toward the general pub-
lic; see “All Is Now Ready,” and “Exhibition Opened,” Gazette, 18 November 1908, 8–9;
and Minnett.
29. On Burland’s life, see C. W. Parker, ed., Who’s Who and Why (Vancouver, 1914),
153. The quotes on the building are from William Henry Atherton, Montreal under
British Rule (Montreal, 1914), 446–47. Burland chose Belmont Park as the location and
procured options on a property there in 1908; see “Meeting of the General Committee
for Exhibition,” 15 October 1908. He subsequently purchased 45 Belmont Park for the
institute: see entry for 16 December 1913, Minutes of Board of Management, Royal Ed-
ward Institute, Vol. 5 (11 June 1909 to 14 November 1922), MCI Library Collection.
30. The patient population was mixed. The four most frequent ethnic classifications
listed were: French Canadians, 1,201 (68 percent); English, 138 (8 percent); Canadians,
87 (5 percent); and Jews, 77 (4 percent). Another branch of our larger research project
looks at the different approaches to tuberculosis treatment accorded these groups.
31. See Atherton, 447.
917
OCTOBER
2008
VOL. 49
FIG. 4 Open-air school on the Royal Edward Institute veranda. (Reproduced

burgh’s Victoria Dispensary for Consumption in 1882. Photographic evi-

dence in the annual reports, however, shows that soon after its opening, the
Royal Edward Institute began to offer in-house rest therapy as a remedy for
tuberculosis. In 1911, a “limited number of patients” began treatment by
the “open air method on the galleries of the Institute”: ten patients received
treatment during both day and night on the galleries, while sixteen came to
the galleries during the day but returned home every evening.32
In December 1912, an associated “open-air” school for students be-
tween the ages of seven and fifteen opened on the veranda.33 The 1913 An-
nual Report includes photographs of children in the back garden of the
institute, surrounded by light canvas and wooden cots, and of children hav-
ing lessons on a veranda in February (fig. 4). The photographs depict the
teacher and a dozen or so students wearing hats and coats, or wrapped in
blankets, even though they are inside. In the same photo, the angelic figure
of a uniformed nurse, who appears to have arrived from inside the build-
ing, contrasts starkly with their dark and heavy clothing.
Some patients at the hospital have left accounts that tell us about the
routine in the 1909 building. Frederick Lear (1909–1999), the son of an up-
holsterer in Montreal’s working-class Pointe-Saint-Charles district, recalled
32. The Annual Report of the Royal Edward Institute for the Study, Prevention, and
Cure of Tuberculosis 2 (1911).
33. According to Harding (p. 18), it was later relocated to a small structure behind
the main house.
918
in a 1990 letter the daily routine he had experienced while attending the
school in 1917: “We had lessons in the morning, a midday meal at noon, and
then had to lie down for a period, before being sent home,” he writes.34 New
technologies arrived only slowly. The hospital installed an X-ray machine at
Belmont at the end of 1923, and a quartz lamp in 1926. The Annual Report
for that year states: “Pulmonary cases do not show great improvement under
the Lamp [sic], but it has been found very beneficial in cases of enlarged
glands of the neck and tuberculosis of the peritoneum.” The quartz lamp
room apparently opened in the last five months of 1926, during which time
“79 cases have been under treatment, with a total of 1,033 exposures.” To
sum up: by the interwar period, many experts believed that the patient’s
material setting could effectively treat the disease. State-of-the-art tubercu-
losis therapy—education, good food, and rest—was organized and imple-
mented through an architecture whose imagery was primarily domestic.
Part 2, 1933: Changes in Site and Services
Our second moment shows a different configuration of technologies, as

buildings began to support and accommodate new tuberculosis therapies.
Displaced by the construction of Montreal’s new central train station in
1933, the institute moved north of the downtown commercial core to its
present location on St. Urbain Street, just south of Pine Avenue, near Mc-
Gill University and the Royal Victoria Hospital, one of McGill’s interna-
tionally renowned teaching hospitals. This relocation saw the construction
of a purpose-built hospital. It included rooms and areas for the tuberculo-
sis cure of sunlight and fresh air. But it also saw a new role as a dedicated
container for diagnostic medical technologies like X-rays and growing im-
portance as a headquarters for broader social technologies, including
patient isolation and preventive diagnosis.35 The expanded hospital was a
vital place for tuberculosis treatment in Montreal: of 546 deaths from pul-
monary tuberculosis in Montreal in 1935, 137 (25 percent) involved pa-
tients who had received care at the Royal Edward Institute.36
Scottish-born Montrealer John Smith Archibald (1872–1934), who
designed the 1933 facility, provides an important link between the hospital
and other Montreal institutions. It is important to note also that his design
34. Letter from Frederick Lear to Duncan Campbell, 23 November 1990, 2. He also
remembers a yard with apple trees. See his more detailed “For Family and the Royal Ed-
ward Chest Hospital,” a fascinating firsthand account of his time at the school, 1 Novem-
ber 1993. Both letters are in the MCI Library Collection.
35. Harding (n. 28 above) noted that the death rate from tuberculosis in Montreal
dropped from 210 to 100 per 100,000 over the thirty-year period from 1903 to 1933.
“This indicates a healthier and more sanitary city,” he wrote, “but we like to think that
part of the result is due to the dreams of . . . Col. Burland” (p. 20).
36. The Annual Report of the Royal Edward Institute for the Study, Prevention, and
Cure of Tuberculosis 25 (1935).
919
was not simply for a hospital, but also included a clinic and the Jeffrey Bur-
land School.37 Like the hybrid combination of functions that comprised the
Royal Edward, Archibald’s reputation rested on both hospital and school
commissions: Baron Byng High School (1921), Elizabeth Ballantyne
School, Notre-Dame de Grâce (1921), the Connaught School (1923), the
Woodlands School in Verdun (1931), the Montreal Convalescent Hospital
OCTOBER
(1931), and St. Mary’s Hospital (1931).38
2008 The combined hospital and clinic building was a long, narrow, four-
VOL. 49
story brick structure set perpendicular to the street (fig. 5). Its rectangular
mass was broken only by a one-story entry pavilion protruding from the
building’s northeast elevation. Three taller, arched windows on the second
floor contrasted with the pattern of four rectangular windows on the
ground and third floors. Brick quoins emphasized the corners of the hos-
pital block. In terms of architectural style, the 1933 hospital shared a subtle
neoclassicism with other Archibald designs, visible in its symmetry (except
for the entry) and in details like the quoins, as well as the handsome pair of
probably-concrete urns marking the corners of the main block at the level
of the roof.
Unlike the 1909 institution, the squarish school building of 1933 was
intended for children living in the homes of tuberculosis patients, rather
than for children with tuberculosis themselves. It was and still is visible
from the street to the north of the hospital building. It had a much simpler
plan (fig. 6) than the double-loaded corridor arrangement of the adjacent
hospital. The main floor included an L-shaped room for girls and a rectan-
gular space for boys. These two rooms were disconnected, accessible only
through doorways located on the landing of a central stairway, which also
accommodated small closets. As expected in school buildings of the time,
the walls incorporated large windows mandated for tuberculosis treatment,
37. The two buildings were separated at the request of Isabel May Megarry Burland
(Royal Edward Institute, “Board of Directors Meeting Minutes, 14 July 1931,” MCI
Library Collection). For the life and work of Archibald, see Irena Murray, ed., John S.
Archibald and His Associates: A Guide to the Archive (Montreal, 1990); Irene Puchalski,
“An Analysis of Four Building Types by John S. Archibald, Architect (1872–1934)” (M.A.
thesis, Concordia University, 1991); “John S. Archibald Dies in 63rd Year,” Montreal Daily
Star, 2 March 1934, 1, 3; “John Archibald Funeral Service Set For Tuesday,” Montreal
Daily Herald, 3 March 1934, 1. W. S. Maxwell wrote a moving tribute to his colleague:
“John S. Archibald 1872–1934,” Journal of the Royal Architectural Institute of Canada 11
(March 1934): 44.
38. On school architecture, particularly the techniques of fireproofing, see E. B.
Palmer, “Typical Schools of the Province of Quebec,” Journal of the Royal Architectural
Institute of Canada 4 (September 1927): 327–36. Archibald also worked on a number of
prominent hotels, including the Manoir Richelieu in Murray Bay, Quebec, and alter-
ations to the Hotel Vancouver, the Château Laurier, and the Windsor Hotel. For discus-
sions concerning the settling of his bill for services rendered, see the Royal Edward
Institute Board of Directors meeting minutes of 27 April and 22 June 1934 in the MCI
Library Collection.
920
FIG. 5 The new Royal Edward Institute, designed by John S. Archibald, was
featured in McGill News in 1933, soon after its opening. (Reproduced courtesy
of McGill News.)
for which there are carefully drawn details on the left of Archibald’s extant
plan; Archibald indicated six to eight openings on each wall, four feet wide
and six-and-a-half feet high. Not surprisingly, the 1934 Annual Report re-
ferred to it as the “open window” school.
921
OCTOBER
2008
VOL. 49
FIG. 6 John S. Archibald’s plan of the second floor of the 1933 Royal Edward
Institute. (Redrawn by Clara Shipman; courtesy of the Montreal Chest Institute.)
A detailed description of the new buildings appeared in the 1933 Mc-

Gill News. According to author E. S. Harding (and confirmed by Archibald’s
plan), the ground floor accommodated the patients’ waiting room, con-
sulting and examination rooms, nose and throat departments, and the dis-
922
pensary.39 For the first time, the Royal Edward offered permanent inpatient
beds. Harding noted that the four wards on the third floor contained
twenty-two beds; the second floor held the offices, common room and of-
fices for visiting nurses, X-ray and quartz light departments, laboratory,
and boardroom. In other words, the new building accommodated medical
technologies like X-rays; was a headquarters for broader social technolo-
gies, including patient diagnosis and isolation; and served as a technology
itself with its inclusion of rooms and dedicated areas for the tuberculosis
prescription of sunlight and fresh air. The architecture, with its huge win-
dows, treated patients directly, but now functioned simultaneously as a
warehouse for specialized technological objects. It was also a burgeoning
bureaucratic space for broader social technologies that surveyed a much
larger geographical area; visiting nurses, for example, set out from the
building as agents, fanning out through the city to locate suspected tuber-
culosis patients and their families.40 Technology involved a combination of
spatial conditions a healthy citizen might encounter across the city: school,
hospital, and home.
EXPANSION AND THE SURGICAL MISSION OF THE ROYAL EDWARD

LAURENTIAN HOSPITAL
Four interlocked situations developed within a dozen years of the open-

ing of the Archibald building, forcing rapid and dynamic institutional and
architectural changes: 1) the preeminence of collapse therapy, including an
emphasis on increasingly invasive surgical collapse treatments; 2) the devel-
opment of successful procedures for lung-tissue resection, which then
eclipsed collapse therapies as the preferred surgical intervention; 3) an in-
stitutional alignment in the Royal Edward’s role as a teaching hospital; and,
finally, 4) the advent of antibiotics.
While earlier medical thinking about tuberculosis had emphasized the
rest cure—rest, hygiene, diet, and fresh air—the interwar period witnessed
the rise of collapse therapy for tuberculosis in the United States and Can-
ada.41 From the turn of the twentieth century through the 1940s, practi-
tioners increasingly promulgated procedures that collapsed affected lung
39. Harding, 19. Harding was secretary of the Royal Edward Institute.
40. The 1924 Annual Report of the Royal Edward Institute for the Study, Prevention,
and Cure of Tuberculosis (vol. 14), for instance, lists six “visiting nurses,” including their
“lady superintendent.” The 1937 Annual Report (vol. 27) has a table showing annual sta-
tistics about consultations, nurse visits, and so on from 1909 to 1937.
41. For an outline of collapse therapy in the broader history of tuberculosis, see H.
Herzog, “History of Tuberculosis,” Respiration 65 (1998): 5–15, esp. 11–12; and Dorman-
dy (n. 7 above), 249–63. For a Canadian focus, see Stefan Grzybowski and Edward A.
Allen, “Tuberculosis: 2. History of the Disease in Canada,” Canadian Medical Association
Journal 160 (1999): 1025–28.
923
tissue. They believed that such procedures deprived M. tuberculosis bacilli

of oxygen and hence killed them.42
James Carson first attempted artificial pneumothorax in Liverpool in
1822. The treatment became widespread during the closing years of the
nineteenth century and the first years of the twentieth.43 The twin-bottle
pneumothorax machine used in Canada included a water manometer,
OCTOBER
allowing the operator to accurately gauge the amount of air pumped into
2008 the cavity surrounding the patient’s lungs via a hose and a long needle.
VOL. 49 Surgeons experimented with the design. Most famously, Norman Bethune
invented one bearing his name that actively pumped air into the cavity (fig.
7), which may have been used at the Royal Edward. Doctors and nurses
used flow sheets (fig. 8) to document the pleural pressures of pneumotho-
rax procedures.44 The sheet shown here indicates that the patient received
the treatment twenty-two times between May and October 1948.
Although the annual reports from the first building do not mention
pneumothorax at all, at the Archibald-designed building pneumothorax
treatment was relatively common.45 The earliest available medical charts,
from 1938–39, highlight repeated treatments; for example, a twenty-two-
year-old woman with “bilateral tuberculosis” who was admitted for six
months during 1939 underwent thirty left-sided pneumothorax treat-
ments, as well as phrenic nerve crush.46 Phrenic nerve crush refers to a sur-
gical procedure whereby the phrenic nerve was crushed through a small in-
cision just above the collarbone. This led to temporary paralysis of the
diaphragm on that side, resulting in reduced expansion of that lung for
three to six months. Phrenic nerve crush was therefore another type of col-
lapse therapy; it differed from phrenicectomy, which involved surgical
removal of a segment of the phrenic nerve, causing permanent diaphrag-
matic paralysis on that side. The 1935 Annual Report shows that collapse
therapies were a major activity for the inpatient service, including 88 new
pneumothoraces and 900 “refills” (of previously created pneumothoraces),
as well as 30 pneumolyses (lysis of pleural adhesions), 15 phrenicectomies
(phrenic nerve interruption), and 3 “phrenic crushes.” The report also doc-
42. However, Bryder (n. 7 above) cautions that “the rise of surgical interventions in
the 1930s . . . had more to do with professional interests, and economic and social pres-
sures than with any inherent superiority of surgery over conservative treatment” (p. 157).
43. The traditional account of the history of artificial pneumothorax is in Brown (n.
2 above), 235–80.
44. On the material culture of pneumothorax, see Annmarie Adams and Kevin
Schwartzman, “Pneumothorax Then and Now,” Space and Culture 8, no. 4 (2005):
435–48.
45. The Belmont Park site produced annual reports until 1929. The Royal Edward
Institute vacated the Belmont house in 1930 and occupied temporary quarters until the
Archibald-designed hospital was ready.
46. Unfortunately, the lack of patient records from earlier years makes it impossible
to clarify what treatments did or did not exist at the first facility on the Belmont Park site.
924
FIG. 7 Pneumothorax machine designed by Norman Bethune. (Reproduced

courtesy of the Osler Library of the History of Medicine, McGill University.)
uments 144 persons who received 865 pneumothorax treatments as outpa-

tients—largely refills. Later surgical interventions included thoracoplasty
(fig. 9), in which the surgeon partially removed ribs in order to reduce the
volume of the thoracic cavity and create inward collapse of both the chest
wall and underlying lung (first performed in 1885), and sometimes oblit-
erated the pleural space with a foreign material such as wax or oil (oleotho-
rax, plombage). By 1927, thoracoplasty, which as we mentioned was intro-
duced to North America by Montreal surgeon Edward Archibald, was in
widespread use, standardized in a three- to four-stage technique for pro-
gressive rib resection.47
Although doctors initially carried out the pneumothorax procedures in
generic, sometimes office-like spaces, the increasing use of thoracoplasty and
related interventions eventually created a new kind of tuberculosis patient—
the surgical inpatient—who in turn prompted changes in tuberculosis hos-
pital planning and design. Simultaneously, the use of diagnostic technology,
likewise initially pushed into nonspecialized rooms, began to be housed in
dedicated areas. The two trends mutually reinforced each other. By the open-
47. Archibald (n. 2 above).
925
OCTOBER
2008
VOL. 49
FIG. 8 Record of treatment with artificial pneumothorax notations for a patient

admitted in 1948. (Reproduced courtesy of the Montreal Chest Institute.)
ing of the Royal Edward on St. Urbain Street in 1933, chest radiography was
obtained before, during (fluoroscopy), and after pneumothorax treatment to
characterize tuberculous lesions and estimate the degree of lung collapse
achieved.48 The Montreal Anti-Tuberculosis League poster featured in the
daily Montreal Gazette on 18 November 1955 displays a graph that showed a
steady increase in the number of X-rays since 1943 and advocates: “Have a
48. The utility of X-rays for tuberculosis diagnosis was noted almost immediately;
see the essay by Francis H. Williams, “The X-rays in Medicine,” International Monthly 3
(1901): 42–56, reprinted in From Consumption to Tuberculosis: A Documentary History,
ed. Barbara Gutmann Rosenkranz (New York, 1994), 551–61.
926
FIG. 9 Images of thoracoplasty from a 1961 textbook by B. T. Le Roux, Tech-

niques of Thoracotomy (London: E. & S. Livingstone).
Chest X-ray at least Once a Year” (fig. 10).49 Thus the hospital design was
itself therapeutic, but it also expanded and transformed its spaces in order to
house and cultivate other diagnostic and therapeutic tools.
An additional influence on the institution’s reaction to emerging thera-
peutic technology came from a realignment in Montreal’s hospital net-
work. In 1933, the Royal Edward contracted with McGill University to be-
come an affiliated teaching hospital. In 1941, McGill’s major research and
teaching hospitals, the Royal Victoria and Montreal General, stopped ad-
mitting tuberculosis patients for surgical treatment. The Royal Edward
therefore closed the Burland School and called on hospital-specialist archi-
tect J. Cecil McDougall to renovate part of the 1933 hospital building and
modify the former school so as to create an addition that included an oper-
ating room and surgical ward.50 The operating room opened on 30 Sep-
49. The Montreal Anti-Tuberculosis League was a benevolent organization unre-

lated to the Prevention League that founded the Royal Edward. On the incorporation of
X-ray and other diagnostic technology into the hospital, see Joel D. Howell, “Machines
and Medicine: Technology Transforms the American Hospital,” in The American General
Hospital: Communities and Social Contexts, ed. D. E. Long and J. Golden (Ithaca, N.Y.,
1989), 109–34.
50. See Howard Murray, “Royal Edward Laurentian Hospital: Its History; an Aide-
Memoire,” typescript, p. 8, in the MCI Library Collection.
927
OCTOBER
2008
VOL. 49
FIG. 10 Montreal Anti-Tuberculosis League advertisement in the Gazette,

18 November 1955. (Reproduced courtesy of the Montreal Chest Institute.)
928
tember 1942, in which year there were eleven “major operations” per-
formed.51 During the next five years, surgery—usually thoracoplasty—be-
came a common treatment.52
STREPTOMYCIN
The most famous innovation in tuberculosis treatment was the intro-

duction of streptomycin and other chemotherapeutic agents.53 Antibiotic
medicine—the first therapy to directly and specifically target the tubercle
bacillus—augured the end of specialized tuberculosis-treatment settings.
Streptomycin was first isolated in the laboratory of Selman Abraham Waks-
man at Rutgers University in 1943 and was first administered for human
tuberculosis treatment in Minnesota in November 1944.54 It was tested in
Canada as early as 1945.55 Three of thirty consecutive Royal Edward patient
files reviewed from 1947 mention its use. In 1949, sanatorium patients in
Quebec could receive antibiotic treatment free of charge.56 Top federal offi-
cials cautiously endorsed the new therapy: “Streptomycin is not a cure-all
for tuberculosis, Mr. Martin [Canada’s Minister of National Health and
Welfare] emphasized, but in certain cases it has proven effective not only in
arresting the disease but also in reducing the time in hospital and in has-
tening the patient’s return to normal activity.” 57
As the Royal Edward Laurentian Hospital (a 350-bed sanatorium divi-
sion in Ste-Agathe, ninety kilometers north of Montreal, discussed below)
sought to expand its surgical services, the development and production of
antituberculous drugs were reshaping the approach to tuberculosis treat-
ment and care. Nurses administered streptomycin bedside, in the hospital
room, or at home. Royal Edward nurses kept track of the procedure on the
51. By 1946, there were sixty-four first-stage thoracoplasties, ninety-three “other-

stage” thoracoplasties, and two pneumonectomies performed at the Montreal hospital.
Our review of thirty consecutive patient medical charts from 1947 also highlighted the
growing use of thoracoplasty, which was documented for ten of these patients, while not
even being mentioned in the 1938–39 case files.
52. On the history of thoracic surgery and surgeons in Montreal, see Delarve (n. 27
above), 21–49.
53. Ryan (n. 11 above) recounts the history of the “intimate details of how the cure
was found” (p. xvii).
54. On this treatment in Minnesota, see K. H. Pfuetze et al., “The First Clinical Trial
of Streptomycin in Human Tuberculosis,” American Review of Tuberculosis 71 (1955):
752–54; on Selman Abraham Waksman, see Alex Sakula, “Selman Waksman (1888–
1973), Discoverer of Streptomycin: A Centenary Review,” British Journal of Diseases of the
Chest 82 (1988): 23–31.
55. “Streptomycin Being Tested As a Cure for Tuberculosis,” Montreal Star, 10 July
1945, 3–4.
56. Oastler (n. 9 above), 1.
57. Ibid.
929
OCTOBER
2008
VOL. 49
FIG. 11 Chart showing administration of streptomycin immediately after a

second-stage thoracoplasty, 1949. (Reproduced courtesy of the Montreal
Chest Institute.)
vital sign (fever) chart; the use of medications is color coded (fig. 11), namely,
there is a red bar used to shade a box under the vital signs for every day that
streptomycin was given. In October 1949, the Montreal Star reported that “in
the highly fatal types of generalized tuberculosis streptomycin frequently
brings about a striking clinical remission.” 58 In 1951, the Gazette reported
that the combination of streptomycin and para-amino-salicylic acid had led
to “moderate” or “marked” improvement in thirty-five patients.59
58. Montreal Star, 25 October 1949.

59. Brian Cahill, “Combination of 2 Drugs Reported Best T.B. Control of Treatment
Yet,” Gazette, 9 August 1951, 13; N. Lewin and M. Aronovitch, “Para-amino-salicylic Acid
with Streptomycin in Pulmonary Tuberculosis,” Canadian Medical Association Journal 65
(1951): 140–44. Our review of thirty Royal Edward patient files from 1951 yielded thir-
teen in which streptomycin was administered, sometimes in combination with para-
amino-salicylic acid.
930
FIG. 12 Hugh Burke, director of the Royal Edward, pictured with Edith Mankie-
wicz in 1955 in press coverage of her work on diagnostic techniques for tuber-
culosis. (Reproduced courtesy of the Montreal Chest Institute.)
SURGICAL THERAPY
Rapid changes followed streptomycin. By the 1940s, hospital leaders in

Montreal perceived that demand for inpatient tuberculosis care greatly out-
stripped available resources. In August 1945, at the close of World War II,
Hugh Burke (fig. 12), medical director of the Royal Edward’s Montreal divi-
sion, indicated that the Montreal hospital was supervising 3,002 persons
with tuberculosis, including 1,214 persons with “moderately far-advanced”
and 290 with “far-advanced” tuberculosis. On 1 August 1945, 530 of these
3,002 were hospitalized at the Montreal or Laurentian divisions or at the
Grace Dart Home Hospital in Montreal; 70 percent of these individuals
were sputum culture–positive. An additional 243 patients were described as
“anxiously awaiting beds in hospital at this moment. . . . 90% of these 243
patients had tubercle bacilli in their sputum at the time of their last exami-
nation.” 60
In a 1945 postwar memorandum, Burke maintained that
it has become clear, with the development of surgical procedures for
the control of tuberculosis . . . that the Hospital does not have ade-
quate facilities for the active treatment of this disease . . . 54 of the 87
60. Hugh E. Burke, “Memorandum Regarding Post-war Expansion of the Royal Ed-
ward Laurentian Hospital,” memorandum dated 14 June 1945, MCI Library Collection.
931
patients whose names are on the admission list of the Hospital’s

Montreal unit at this moment are awaiting surgical procedures.61
The hospital therefore proposed to nearly quadruple its bed capacity—
from 52 (“taxed to capacity”) to 200, including six 30-bed wards and one
20-bed ward (with one ward reserved for children)—to add a second oper-
OCTOBER ating room, and, finally, to construct accommodation for a hundred nurses
and sixty other staff.62 This last category, “other staff,” included X-ray tech-
2008
nicians, dietitians, and social workers. Annual reports distinguish among
VOL. 49 medical staff responsible for inpatients, surgical staff, and “dispensary
staff ” physicians who were responsible for outpatient care. For example,
the 1945 report for the Montreal division (i.e., the Royal Edward) cites both
a medical director (Burke) for the Montreal site and an assistant medical
director. It lists a surgeon-in-chief, two additional surgeons, four associate
surgeons, one assistant to the surgeon-in-chief, and one “assistant in sur-
gery.” For the dispensary, it notes eight physicians, twelve associate physi-
cians, and three “voluntary assistants.” There was also a medical microbiol-
ogist. Surprisingly, documentation as to the number of inpatient nursing
positions on St. Urbain is consistently absent from the annual reports.
There were fifteen full-time and one part-time public health nurses, with
their own superintendent.
Part 3, 1954: The Surgical and Laboratory Building
Despite the growing use of both antimicrobials and resectional surgery,

Burke continued to promote rest therapy—and thus inpatient-treatment
facilities that included balconies, galleries, and extensive glazing. As medical
historian Julius Comroe Jr. puts it, doctors were “reluctant to let patients get
out of bed.” 63 In 1956, Burke delivered a scientific paper at the Canadian
Medical Association’s annual meeting citing evidence from guinea pig
experiments that treadmill exercise was associated with shortened survival
after intrapleural inoculation of M. tuberculosis bacilli: “rest favours the
healing of areas of tuberculous infection, as demonstrated in the survival of
three of the group of ‘resting’ animals.” 64 This echoed a 1954 official state-
ment from the American Trudeau Society that emphasized the continued
role of rest therapy. The American Trudeau Society’s Committee on Therapy
acknowledged “continuing reports showing the increased effectiveness of
61. Ibid.
62. Ibid.
63. Comroe reviews the evolution of treatment through published textbooks; see
“T.B. or not T.B.? Part II. The Treatment of Tuberculosis,” American Review of Respiratory
Disease 117 (1978): 379–89, quote on 387.
64. Burke, address to the Canadian Medical Association’s 89th Annual Meeting,
Quebec City, 11–15 June 1956, reported in the Gazette, 15 June 1956.
932
FIG. 13 The Royal Edward Surgical Tower, designed by the architectural firm
McDougall, Smith, & Fleming, under construction in 1953. (Reproduced
antimicrobial therapy in the treatment of pulmonary tuberculosis have

caused many physicians to question the necessity or advisability of pro-
longed bed rest.” However, it concluded that “from the facts now available,
there is no evidence to support a reduction in the amount of rest therapy
from that of past practices except as this may be justified by an earlier attain-
ment of an inactive status of the disease.” 65 The new therapies were super-
imposed on the conceptual and material infrastructure of the old.
Even with the advent of isoniazid—the most powerful antituberculous
agent yet developed—medical authorities remained skeptical. George
Wherrett, executive secretary of the Canadian Tuberculosis Association,
wrote in 1952 that despite the development of chemotherapies, “There will
be no reduction in the need for hospital beds. . . . It cannot be too strongly
emphasized that neither streptomycin nor isoniazid replace the well-tried
methods of treatment by bed rest in the sanatorium and surgery in selected
cases.” Therefore, in 1952, the Royal Edward’s Montreal site saw the con-
struction of a sleek modern tower dedicated to surgical procedures, by the
architectural firm of McDougall, Smith, & Fleming (fig. 13).66 Located just
south of the 1933 Archibald-designed hospital on St. Urbain and connected
65. American Review of Tuberculosis 69 (1954): 1069–70.

66. The construction process is comprehensively recorded in an outstanding num-
bered series of eight photographs taken between January 1952 and January 1953. These
photographs are in the MCI Library Collection.
933
to its older neighbor by an overhead bridge on the second floor, the new
long, narrow surgical tower stretched approximately 180 feet from St. Ur-
bain to an alley in the rear. The main portion of the building was six stories
high (two additional stories were added in 1957). The overhead bridge from
the older building joined the tower’s second floor through an L-shaped
wing, just behind the main entry. During 1956, bed capacity there increased
OCTOBER
from 81 to 131 patients with the completion of three additional floors.67
2008 The new building, however, was not designed to accommodate patients for
VOL. 49
the rest cure, but worked in conjunction with the other (Laurentian) arm of
the institution, which was located in a picturesque rural setting.
Inside, the architect’s design of the new hospital showcased four-bed
wards and private rooms along a double-loaded corridor (fig. 14). McDou-
gall, Smith, & Fleming’s plan shows accommodation on a typical floor for
twenty-five patients: twenty in the wards, and five in private rooms. At the
end of the long building, a gallery next to the smokestack faced the alley-
way; near the center, public waiting rooms, flanked by offices for the head
nurse and medical personnel, protruded from the building’s south face.
The section of the tower directly above the attractive entry, projecting
north, held the elevator banks and large ward kitchens. From the exterior,
however, these spaces appeared identical in elevation to the patient rooms.
In terms of general appearance, the new hospital building resembled a
high-rise office tower, with its crisp edges and windows forming bands or
ribbons. Unlike the 1933 building, the new one even turned a relatively
blank façade to the street (fig. 15); indeed, the most interesting architec-
tural feature of the tower was the bold, protruding double-height entrance,
set back forty-five feet from St. Urbain and constructed of Queenston lime-
stone like the ground story of the tower section nearest the street.
How did the architecture of a chest hospital differ from a general hos-
pital? Not radically. Postwar chest hospitals look like other postwar hospi-
tals. McDougall, Smith, & Fleming designed several other remarkably sim-
ilar institutions, especially the 1956 Montreal Children’s Hospital. Both the
Royal Edward and the Children’s Hospital are high-rise brick blocks with
rectangular footprints, ziggurat-like silhouettes, window configurations
stressing horizontal movement, and iconic chimneys. As hospitals became
less like civic monuments or large houses and more like urban office tow-
ers, however, the interior arrangement remained obsessively specialized. In
McDougall, Smith, & Fleming’s Montreal General, for example, different
types of patients are stacked in a complicated nosological and social dia-
gram, which is only connected by vertical circulation through disconnected
stair towers and elevators (fig. 16).
67. However, on 31 December 1956, 96 of the 131 beds were occupied, as compared
with 72 of 81 beds on 1 January of the same year (Report—Royal Edward Laurentian
Hospital 16 [1957]).
934
FIG. 14 The plan of the Royal Edward Surgical Tower, 1954. (Redrawn by
Clara Shipman; courtesy of the Montreal Chest Institute.)
935
OCTOBER
2008
VOL. 49
FIG. 15 The Royal Edward Surgical Tower pictured soon after the opening of the
first six floors in 1954. (Reproduced courtesy of the Montreal Chest Institute.)
Postwar towers of all types (medical and nonmedical) are distinguished

by an absence of any spatial hierarchies. Despite the functionalistic rheto-
ric of form following function, discrete functional zones are not apparent:
corridors, lobbies, living rooms, offices, and even lavatories might all sport
the same floor-to-ceiling heights and fenestration. A comprehensive survey
of chest hospitals in North America may show, in fact, that the broadening
of tuberculosis hospitals’ vocation at this time to include patients with
other chest problems paralleled the move to a more standardized hospital
building. Still, the vertical separation of patients by nature of their condi-
tion remained. Once the Royal Edward began to accept patients with con-
ditions other than tuberculosis, for example, tuberculosis patients were
housed on the top floor of the older building, clearly separated from the
others with nontuberculosis ailments.68
After Chemotherapy
With these changes in architectural planning and imagery, the building

helped determine the unfolding changes in treatment. In the 1953 Annual
68. Personal interview with Mary Phung, 20 July 2007; Phung began working at the
MCI in 1965 and retired in 1991.
936
FIG. 16 Axonometric diagram of zoned areas at the Montreal General Hospital

(from Journal of the Royal Architectural Institute of Canada 32 [September
1955]: 314). (Reproduced courtesy of the Royal Architectural Institute of
Canada.)
Report, immediately before the opening of the new surgical and laboratory
building, Burke stated:
The numbers of minor operations carried out for the purpose of
permitting better collapse of an area of disease in a lung have dwin-
dled almost to the vanishing point. This turn of events is a direct
result of the fact that, due to an upsurge in interest in pneumoperi-
toneum therapy [an alternate form of collapse therapy], the advent
of effective anti-tuberculous [sic] chemotherapeutic agents, and a
growing interest in resection surgery, few attempts have been made
to institute pneumothorax therapy. . . . Growing appreciation of the
fact that recently developed forms of treatment—i.e.: chemotherapy
and resection surgery—have more to offer many patients who in the
past almost certainly would have been considered suitable candidates
for collapse therapy, is largely responsible for the decline in the num-
bers of thoracoplasty operations from 136 in 1948 to 25 last year. . . .
937
Ten resection operations were carried out in 1948 . . . forty-two

this past year.69
From the surgical standpoint, interest in collapse therapies had waned in
favor of resection of diseased lung tissue, first conducted successfully in
1934 in Montreal by surgeon Edward Archibald (hence the larger numbers
OCTOBER of resections as compared with thoracoplasties).70 In 1941, just three years
before streptomycin was tested on human patients, Archibald used an un-
2008
usual architectural metaphor to express his belief in the efficacy of surgical
VOL. 49 treatment for tuberculosis: “The foundations have been well and truly laid.
Most of the superstructure has already been added. What remains to be
done cannot be much more than detail work.” 71
Once chemotherapy was part of the treatment armamentarium, the typ-
ical patient actually received three very different therapies, recapitulating the
development of therapeutic technology since the beginning of the century:
the rest cure, surgical intervention, and chemotherapy. In 1942, the Royal
Edward Institute had merged with the Laurentian Sanatorium Association
(fig. 17) to form the Royal Edward Laurentian Hospital, composed of Mon-
treal and Laurentian divisions.72 The newly merged hospital instituted a net-
work of facilities between which patients traveled for different types of treat-
ment. As Royal Edward director F. Learn Phelps recounted in 1957, there
was no need for a single massive, centralized facility supporting surgery, rest,
and drug therapy:
As in previous years the drug treatment of our cases has been con-
centrated on any two of the three drugs, streptomycin, P.A.S. and
I.N.H. When possible the length of treatment has been set at one
year in the sanitarium [sic]. The results have been most amazing in
some early cases. However the older or chronic cases can be helped
only. Destroyed tissue is hard to replace. Surgery in some form has
been used in the eighty-two cases referred to our Montreal Division.
Most of these cases returned to Ste-Agathe for post surgical care
of some months.73
69. Report—Royal Edward Laurentian Hospital 12 (1953).

70. Archibald (n. 2 above), 319. During 1953, 159 patients were admitted to the
Montreal hospital’s surgical unit. The 1953 Annual Report documents 247 “minor opera-
tions,” primarily diagnostic bronchoscopies and related procedures. There were 82
“major operations,” including 25 thoracoplasties, 9 pneumonectomies, and 31 lobec-
tomies and/or wedge resections of lung tissue.
71. Archibald, 323.
72. These two sites continued to operate as a merged institution until 1963, when the
Quebec Hospitals Act mandated their separation. The Montreal site was then renamed
the Royal Edward Chest Hospital.
73. F. Learn Phelps, Report—Royal Edward Laurentian Hospital 16 (1957): 16.
938
FIG. 17 Postcard showing pavilions of the Royal Edward Laurentian Hospital,

Ste-Agathe division. (Reproduced courtesy of the Bibliothèque et Archives
nationales du Québec.)
Rest could be managed in the sanatorium at Ste-Agathe; drug therapy

at home; and surgery in Montreal.74 Patients could travel between facilities.
So even though antibiotics were transportable, the patient was passed from
building to building—as if the distinct architecture of each location con-
tinued to contribute to and influence the course of treatment. Architecture
housed rooms and installations for specialized therapies (rest cure) and
machines (X-rays), and, in turn, changes in technology initiated changes
in building programs (operating rooms for surgery). Even as treatment
seemed to be less intricate because of the efficacy of drugs, therapy had in
fact become more complex, involving multiple, overlapping technologies
and procedures, carried out in multiple therapeutic settings.
74. Ronald Bayne recounts his experience at the sanatorium in Ste-Agathe during
1948–49, at the end of which he received an experimental trial of streptomycin; he was
at the time a resident in pediatrics at the Children’s Memorial Hospital in Montreal. See
“Ascending the Magic Mountain,” Canadian Medical Association Journal 159 (1998): 258,
517–18.
939
Conclusion: From Tuberculosis to Lung Disease
The tuberculosis hospital was adjusted to become the center of a differ-

ent institution. Specialized architecture was reconceived and repurposed
from tuberculosis treatment only to a more general thoracic hospital. On
1 January 1956, a change in hospital policy allowed for the admission of per-
OCTOBER
sons with nonpulmonary tuberculosis, while on 19 September it became
2008 possible “for members of this Hospital’s staff to arrange to have patients who
VOL. 49
have chest conditions of uncertain etiology admitted for investigation and,
if indicated, treatment.” 75 In 1957, the first patients with chest conditions of
uncertain etiology were admitted: 40 of them that year, as opposed to over
300 with tuberculosis, of which 286 were pulmonary or pleural.76 Prior to
these developments, on 24 January 1955 the first baby was born onsite, to a
mother with tuberculosis, in the hospital’s obstetrical unit, which was on the
third floor of the old building.77
Not only was there insufficient room in the expanded building for pa-
tients diagnosed with tuberculosis, but the institute also needed to provide
services for tuberculosis patients who developed other conditions. This
need was exacerbated by the fact that the general hospitals no longer wished
to provide any tuberculosis care.78 The Royal Edward began to move away,
then, from caring only for persons who had tuberculosis (in some instances
with additional, coexisting conditions) toward treating those with undiffer-
entiated and ultimately nontuberculous chest problems. The 1960 Annual
Report is the first to mention lung cancer: sixty patients “proved to have
lung cancer,” and there were eleven major operations for it. In that year, 582
nontuberculous patients were admitted (including 78 with lung cancer),
double that of 1959. Likewise, outpatient drug therapy had risen from 381
at the end of 1959 to 560 two years later. In 1961, there were 195 major
operations, including 57 nontuberculous-related lung resections. In other
words, antibiotics affected tuberculosis care on many fronts, for not only
were they important therapeutic agents themselves, but they also improved
outcomes after surgical operations, including thoracoplasty and lung resec-
tion.79 By 1963, the pulmonary tuberculosis service reduced to twenty-five
beds, while nontuberculosis treatment included over a hundred.
What then does hospital architecture tell us about the reception of
75. Report—Royal Edward Laurentian Hospital 15 (1956): 21.

76. Report—Royal Edward Laurentian Hospital 16 (1957).
77. The baby’s name featured the initials R. E. L., after the hospital. This was report-
ed in Report—Royal Edward Laurentian Hospital 14 (1955).
78. In his memorandum dated 14 June 1945 (n. 60 above), Burke wrote explicitly
that “It seems clear that this Hospital must, in its plans for expansion, make provision for
a limited number of beds for the treatment of patients with infectious tuberculosis in
whom non-tuberculous conditions requiring attention develop.”
79. Herzog (n. 41 above), 12.
940
streptomycin? An earlier hypothesis presented by one of us (Adams) in

2002 by means of a timeline pointed out the difficulty of reconciling the
drug treatment and tuberculosis architecture.80 As an architectural histo-
rian, Adams speculated that the absence of direct links between tuberculo-
sis architecture and the use of therapies indicated that medical architecture
was shaped by other, nonmedical forces. This suggestion contests the as-
sumption in classic histories of hospital architecture that hospital design
illustrates medical theories. Adams showed how the advent of antibiotics
actually lagged behind major developments in tuberculosis-related design,
rather than driving architectural innovation.
In many ways, this case study of the Royal Edward tests and confirms
the incongruities noted in that initial speculative survey of building design
for tuberculous treatment. In particular, the next architectural stage of our
case study suggests surprising doubts about the effectiveness of antibiotics,
expressed in the ways medical spaces were used; surprising because the
introduction of drug therapy seemed to promise the large-scale elimination
of tuberculosis, especially when considered in conjunction with the treat-
ments of other bacterial infections at the end of World War II.81 The hos-
pital shifted from being primarily concerned with a particular disease, tu-
berculosis, to broadening that concern to an entire organ, the lung. A
similar process of generalization took place in another free-standing tuber-
culosis hospital, Denver’s National Jewish Hospital, which is now a leading
respiratory research and care center.
Traditional architectural history suggests that buildings should be stud-
ied through the ideas of those who commission and conceive them—in this
case, doctors and architects. Medical histories typically claim that buildings
illustrate medical progress. This case study instead shows that architecture,
studied through its changing uses, actually slowed medical innovation. The
story of tuberculosis therapy at the Royal Edward is a superb example of
the notion that buildings are more than reflections of societal values; rath-
80. The timeline was presented by Adams in “Porches and Pills: The Architecture of
Postwar Tuberculosis,” Society for the Social History of Medicine, Sheffield, UK, 23–25
March 2002. A book of papers from the conference is under review: Flurin Condrau and
Michael Worboys, eds., From Urban Penalty to Global Emergency: Current Issues in the
History of Tuberculosis.
81. In some ways, the switch away from tuberculosis was probably easiest for thoracic
surgeons. Having established techniques for lung resection and postoperative care, these
could be immediately extended to lung resection for other pathologies. If the Royal Ed-
ward was the “market leader” in thoracic surgery (and thoracic surgery was localized
there), it was not much of a stretch to shift to other pathologies, as the need for nontu-
berculosis surgery increased and that for tuberculosis surgery disappeared. It was proba-
bly more difficult for medical (nonsurgeon) chest specialists, in the sense that the spec-
trum of disease and treatment was quite different for nontuberculosis conditions: a
mixture of acute infections—namely, pneumonia—with chronic noninfectious condi-
tions such as asthma or emphysema.
941
er, the context, use, and histories of buildings contribute to architectural

meaning. The Royal Edward (and especially Burke) backed surgery treat-
ments when antituberculous drugs appeared on the scene as a seemingly
miraculous cure. The surgeons were wrong. This is a rare instance of archi-
tecture as evidence of what doctors wanted but patients didn’t need.
Using architectural and material evidence to gauge physicians’ initial
OCTOBER
responses to chemotherapy opens the door to myriad studies. The interac-
2008 tion of architecture and medicine is crucial here. When we study the over-
VOL. 49
laps between tuberculosis and technology by charting the rise and fall of
tuberculosis collapse therapies against the Royal Edward’s architectural
expansions, it becomes clear that pneumothorax therapy began to decline
once operating rooms were available for major surgery. New and old tech-
nologies—the various realms of clinical practice, medical innovation, ma-
chines, and buildings—interact and develop in only partial autonomy;
both surgery and surgical space are necessary components of the medical
practices that linked environment-based cures and the full deployment of
chemotherapies. The lesson here is to study the progress and adaptation of
new technologies as a nonlinear, multifactorial process in which architec-
ture is both a technological support and is itself a significant technology.
Form does not simply follow function. Like other medical technologies,
architecture can impose constraints when it comes to deciding which treat-
ments are feasible or not or which are to be used in a particular setting;
architecture embodies choices about health care, imposing consequences
on these choices. Place—the material environment and its symbolic cul-
tural meanings—must be integrated into any understanding of tuberculo-
sis technologies, no matter how portable, ephemeral, or intangible. Archi-
tecture matters.
942
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Collapse and Expand: Architecture and Tuberculosis Therapy in Montreal,

Article in Technology and Culture · November 2008

Annmarie Adams Kevin Schwartzman

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ANNMARIE ADAMS, KEVIN SCHWARTZMAN,

During the mid-twentieth century, Montreal’s Royal Edward Laurentian

Annmarie Adams is William C. Macdonald Professor of Architecture at McGill Univer-

ADAMS et al.K|KArchitecture and Tuberculosis Therapy in Montreal

Studying the Royal Edward’s history allows us to juxtapose medical and

FIG. 2 Telegraph switch wired to open doors with a transatlantic signal at

Whereas in 1909 the opening was an international social occasion with a

ADAMS et al.K|KArchitecture and Tuberculosis Therapy in Montreal

gies and, conversely, on how technology adjusts and adapts to different

The Technologies of Tuberculosis Therapy

Our aim is to understand how new technologies overlap, displace, and

5. Scholars of medical technology rarely discuss the hospital itself as a technology.

ment of tuberculosis: the fresh-air cure, collapse therapy, surgical therapy,

7. Other tuberculosis therapies included such “quack” remedies as gold treatment,

ADAMS et al.K|KArchitecture and Tuberculosis Therapy in Montreal

In the timeframe under study, the role of technology is vital to under-

ADAMS et al.K|KArchitecture and Tuberculosis Therapy in Montreal

modernism.21 Architects specified expansive areas of glass in order to max-

transform their daily practices into action by emulating the demonstra-

Part 1, 1909: Establishment of the Royal Edward Institute

The Montreal Chest Institute began in October 1909 as a tuberculosis

25. The impact of antituberculosis thinking on Montreal home life is explored in

ADAMS et al.K|KArchitecture and Tuberculosis Therapy in Montreal

FIG. 3 Royal Edward Institute (1909) on Belmont Park, Montreal, as shown in

FIG. 4 Open-air school on the Royal Edward Institute veranda. (Reproduced

burgh’s Victoria Dispensary for Consumption in 1882. Photographic evi-

ADAMS et al.K|KArchitecture and Tuberculosis Therapy in Montreal

Part 2, 1933: Changes in Site and Services

Our second moment shows a different configuration of technologies, as

ADAMS et al.K|KArchitecture and Tuberculosis Therapy in Montreal

A detailed description of the new buildings appeared in the 1933 Mc-

ADAMS et al.K|KArchitecture and Tuberculosis Therapy in Montreal

EXPANSION AND THE SURGICAL MISSION OF THE ROYAL EDWARD

Four interlocked situations developed within a dozen years of the open-

tissue. They believed that such procedures deprived M. tuberculosis bacilli

ADAMS et al.K|KArchitecture and Tuberculosis Therapy in Montreal

FIG. 7 Pneumothorax machine designed by Norman Bethune. (Reproduced

uments 144 persons who received 865 pneumothorax treatments as outpa-

47. Archibald (n. 2 above).

FIG. 8 Record of treatment with artificial pneumothorax notations for a patient

ADAMS et al.K|KArchitecture and Tuberculosis Therapy in Montreal

FIG. 9 Images of thoracoplasty from a 1961 textbook by B. T. Le Roux, Tech-

49. The Montreal Anti-Tuberculosis League was a benevolent organization unre-

FIG. 10 Montreal Anti-Tuberculosis League advertisement in the Gazette,

ADAMS et al.K|KArchitecture and Tuberculosis Therapy in Montreal

The most famous innovation in tuberculosis treatment was the intro-

51. By 1946, there were sixty-four first-stage thoracoplasties, ninety-three “other-

FIG. 11 Chart showing administration of streptomycin immediately after a

58. Montreal Star, 25 October 1949.

ADAMS et al.K|KArchitecture and Tuberculosis Therapy in Montreal

Rapid changes followed streptomycin. By the 1940s, hospital leaders in