Medicine by Design: The Architect and the Modern Hospital, 1893–1943

  • AnnMarie Adams
University of Minnesota Press: 2008. 240 pp. $82.50 9780816651139 | ISBN: 978-0-8166-5113-9

The twentieth century saw the beginnings of modern scientific medicine and a shift in hospital architecture. Did good design catalyse medical progress during this period, or did medical practice dictate what was built?

Credit: ALUMNAE ASSOC. ROYAL VICTORIA HOSPITAL TRAINING SCHOOL FOR NURSES

AnnMarie Adams's careful and delightful book analyses hospital design between the late-Victorian scientific revolution of the 1890s and the Second World War. Adams, an architectural historian at McGill University in Montreal, uses the city's Royal Victoria Hospital (pictured) as her centre-piece. Around it she weaves carefully researched stories of other hospitals, architects, physicians and governors involved in the development of North American hospitals.

Adams questions the assumption held by medical and architectural historians that hospitals passively reflect evolving practice and innovation in medicine. She explores how physicians and architects worked together to invent the modern hospital. As hospital architects learned more about medicine, they began to offer practical and innovative solutions, as in the case of lighting for operating theatres and choice of materials that support hygiene. At the same time, some physicians acted as consultants on multiple design projects and lectured at conventions on design topics.

Medicine by Design contends that inter-war hospital architecture “anticipated and produced medical practices that were broadly and socially conceived”. Service to the poor at a time when few effective cures were available was replaced by a mission to treat the sick as medicine improved. Hospital buildings began to reflect social strata with separate facilities for the wealthy on upper floors. The evolving professional status of nurses brought nursing schools, and with it, highly regulated, supervised dormitory housing shaped by paternalistic concerns for young unmarried women leaving the protection of the traditional home.

Between the wars, hospital architects began to separate the functional planning of a building from its aesthetic design. Adams notes that hospitals were slow to adopt the unornamented style of modern architecture so popular in the 1920s and 1930s, favouring Georgian or neo-classical aesthetic. Well-ventilated pavilions, developed while medicine was dominated by the 'miasma' theory, gave way to block planning as Louis Pasteur's germ theory advanced. The latter provided more segregated spaces and greater distances from open windows, and allowed physicians to control airflow and cleanliness.

As surgeons made the transition from gentlemen's attire to gloves, masks and gowns, and used Joseph Lister's carbolic acid spray on wounds, architects designed new operating theatres with abundant natural and artificial light, space for new equipment, and resilient surfaces that could be cleaned with harsh chemicals. The prevailing 30-bed wards were replaced by separate rooms of two to eight beds each, arranged along both sides of a central corridor. These rooms and spaces for large machines such as Wilhelm Röntgen's X-ray apparatus or for elaborate hydrotherapy were better suited to buildings with a broader beam span than the typical pavilion.

Adams begins her story with the 1893 opening of the Royal Victoria Hospital, a tribute to Queen Victoria's golden jubilee in 1887 conceived by local civic leaders and physicians with Scottish links — at the time many North American physicians were trained in Edinburgh. British architect Henry Saxon Snell's hospital design drew on the style of a Scottish baronial manor.

Using a wide variety of original sources, Adams describes the evolution of the Royal Vic and other North American hospitals through a succession of projects by prominent and lesser known architects. The Royal Vic and the Johns Hopkins Hospital in Baltimore, Maryland, completed five years earlier, were the first in North America to reflect the new thinking associated with the scientific revolution while still adhering to pavilion-style plans. Physician John Shaw Billings designed Johns Hopkins in collaboration with architects John Niernsee and Cabot & Chandler after touring many of the best European hospitals. Pavilions had become the prevailing design there following the competition to rebuild the Hôtel-Dieu in Paris after the disastrous fire of 1772. Florence Nightingale supported pavilions, advocating hospital wards with large windows between every two beds, but criticized the design of the Royal Vic, where she felt that nurses on the wards would struggle to observe their patients efficiently.

Adams explores the important contribution of Edward Stevens, arguably the first specialist architect of hospitals. Stevens trained at Massachusetts Institute of Technology and made rigorous studies of European and North American hospitals and the practice of medicine. He designed, with Frederick Lee, numerous hospitals across the United States and Canada and wrote the influential guide The American Hospital of the Twentieth Century in 1918. Also influential were physician consultants such as S. S. Goldwater, the superintendent of New York Hospital. Goldwater proposed a design in 1905 for an urban high-rise hospital exploiting the new technologies of structural steel, elevators and electric lights. Although never built, the proposal was quickly followed by numerous designs for such multi-storey hospitals.

With medicine progressing ever faster, Adams' history reminds us why hospital architects and physicians should work together to optimize healthcare environments.