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Designing for tuberculosis

Early 20th century sanatorium architecture reflects dominant treatment paradigms

Imagine, for a moment, that the architecture of a medical building was itself a treatment technology. What would it look like? Throughout the first half of the 20th century, tuberculosis sanatoriums – buildings constructed for the long-term treatment and care of tuberculosis (TB) patients – were just that.

A paper recently published in the journal Technology and Culture, entitled “Collapse and Expand,” juxtaposes the evolution of sanatorium architecture in Montreal with treatment technologies of the time.

The first articulation of the Montreal Chest Institute, known as the Royal Edward, was located where the Queen Elizabeth Hotel stands today. It was built in 1909, and reflected the dominant tuberculosis treatment method of the period: rest therapy. This treatment regime stressed fresh air, sunlight, and good nutrition as being essential to the patient’s recovery. The paper’s lead author, Professor Annmarie Adams in the department of architecture at McGill, explained that in 1912, an “open-air” school for children aged seven-15 afflicted by tuberculosis, opened.

“The really exquisite images we have from the Royal Edward show a school-like situation set up on an open-air porch where casement windows actually flip in and the whole wall of windows is open to the fresh air,” Adams said.

Blue Ridge Sanatorium, in the city of Charlottesville, Virginia, is another example of a sanatorium built with consideration for the physical environment and architecture as a treatment technology. Daniel Bluestone, Professor at the University of Virginia School of Architecture, has studied the architecture of the sanatorium, and has been part of efforts for its preservation.

“They were really built around a notion that patients would basically be confined to their beds for much of the day, but that the beds would be on what amounted to porches that had great ventilation, circulation of air, and a kind of orientation to the sun so that they were flooded with light and air for most of the day,” Bluestone said. He also noted that at Blue Ridge, patients were able to benefit from the agricultural products of the surrounding land, which fit in with doctors’ belief in the importance of good nutrition as a form of treatment.

In 1933, the Royal Edward moved to its Saint Urbain location, south of Pine Avenue, where the current Montreal Chest Institute still stands. This new construction saw continued use of rooms for sunlight and fresh air treatment, but also included specialized rooms to house technologies such as X-ray machines. Two important medical technologies followed the construction of the first Saint Urbain building: surgical procedures, as well as antibiotic treatments.

Beginning in 1942, surgery related to tuberculosis was increasingly conducted at the Royal Edward, when it had previously been performed at the nearby Royal Victoria Hospital. This surgery was usually thoracoplasty, a treatment which involves breaking a patient’s ribs and pushing them into the thoracic cavity in order to collapse the lung beneath. As a result of increased need for surgical operations, a renovation on the 1933 building was undertaken to include an operating room as well as a surgical ward. Streptomycin, the first antibiotic to target the bacterial cause of tuberculosis, was first tested in Canada in 1945 and was soon after used to treat tuberculosis patients at the Royal Edward.

Despite the effectiveness of these two treatments, the architecture in the 1956 construction of an additional tower immediately south of the 1933 building did little to reflect best treatment practices. Adams argued that the hospital’s resistance to new technologies as evident in its architecture, demonstrates its place as a conservative force in tuberculosis treatment.

“Even after streptomycin was developed in the post war era, buildings continued to look like the same old TB sanatoriums – for example, the fresh air porches persisted,” said Adams. “What it teaches us, as a case study, is that medical buildings are really culturally determined more than medically determined.”

Bluestone on the other hand, felt that the changing architecture of buildings at the Blue Ridge Sanatorium did reflect the changes in technologies in the post-war era. “The buildings that were built after the antibiotic regimes came into play were actually much less open to the elements, less concerned with view, less oriented toward the sun, and so you could actually see on the Blue Ridge site the movement from this kind of environmental consciousness to a kind of systems approach where the technology of building and the management of patients trumped this notion of bringing patients in direct contact with light and air and scenery,” Bluestone said.

Adams argued that charting the history of medical buildings is important. “There is a lot of misunderstanding about medical buildings. Historic hospitals are declared obsolete without really studying why or when they became obsolete,” said Adams.

“There is something to be learned from focussing and having in the landscape buildings that help us engage and interpret the history of people in a society pulling together to confront major public health crises,” Bluestone said of the importance of preservation.

And yet, Adams noted that the Montreal Chest Institute in its current form retains little architectural remnants of rest therapy.

“It’s been renovated inside. I can’t think of any room that persists…but you can still see the entrance to the [former school for tuberculosis-affected children],” Adams said.

Professor Annmarie Adams will be speaking as part of a World TB Day seminar on March 24 at 12 p.m. at the Montreal Chest Institute, 3626 Saint Urbain.