Reviewer biography

Current Reviews

Review Articles

Book Reviews Archive

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

by Annmarie Adams
University of Minnesota Press, Minneapolis, 2008
Architecture, Landscape and American Culture Series
169 pp., illus. Trade, $82.50; paper, $27.50
ISBN: 978-0-8166-5113-9; ISBN: 978-0-8166-5114-6.

Reviewed by Leslie Topp
Faculty of Lifelong Learning, Birkbeck
University of London, 26 Russell Square, London, UK

l.topp@bbk.ac.uk

This book derives from an architectural historian’s encounter with the specialist field of hospital building between 1893 and 1943.  The title is misleading in its promise of an international survey of the field.  The focus is almost entirely on Canadian examples, and within Canada, particularly on Montreal. This tight focus does allow the author to give richly detailed account of important ideological, spatial, technological and stylistic questions about hospital architecture in the space of a relatively short book.  But it works better as an evocative case study of the interaction of architecture and medicine in a particular cultural context than it does as an account of modern hospital design generally.

The author repeatedly comes back to a particular hospital, the Royal Victoria, built in several stages in an affluent and geographically elevated part of Montreal from 1893 onwards.  The first chapter discusses the first Royal Victoria Hospital building, as an example of a pavilion plan hospital, the pavilion plan being the standard mode of hospital design until the interwar period.  In the pavilion plan, patients were classified according to the nature of their disease and treatment, and housed in open, easily ventilated wards in low-lying pavilions connected only minimally, if at all, to each other.  Adams shows the importance of a location that was both healthy and prestigious (in Montreal, the higher you were up the side of Mont Royal, the more social status you carried).  The stress placed on location, along with the care taken with its monumental design (in the Scottish Baronial style), she relates to the importance of the hospital as a civic monument as well as a place for medical treatment and research.

Subsequent chapters deal with particular themes and sub-types within the overall hospital building type.  Adams discusses class issues and changes in the way hospitals were planned during and after WWI.  While the first Royal Victoria was a philanthropic institution intended for the city’s poor and middle classes, the Ross Memorial Pavilion, added to the hospital grounds at an even higher point in 1916, was built specifically for patients who could afford to pay.  A combination of the decreasing emphasis on the importance of ventilation and the increasing desire to attract wealthy patients led to smaller wards and more private rooms.  Elevators made it possible to transport patients to specialist treatment centres (rather than having the doctors and equipment come to the patients in the ward).  The high-rise block hospital so familiar from the post-1945 era had its roots in the 1910s and 20s.  But whereas later the international style predominated, and hospitals resembled office blocks, the first block hospitals, such as the Ross Pavilion, drew on the imagery of the grand hotel.  This was also the period of a proliferation of specialist hospital types, including the maternity hospital and the children’s hospital, and of extension into the wider community through the development of dedicated outpatients’ facilities.  An intriguing detail examined by Adams is that at the Royal Victoria and elsewhere while the luxurious paying patients’ pavilion was raised above the rest of the hospital outpatients, who were mostly poor, were seen in a subterranean space.

Hospitals were not only for patients, of course.  They employed huge staffs, some of which lived on site.  In a fascinating discussion of the nurses’ residence and the interns’ building, again at the Royal Victoria, Adams analyses the role of gender. A sense of hominess and spatial control predominated in the former, while the men in the latter were encouraged to be active, mobile and spatially unconstrained.

The final two chapters examine the interaction between the specialist hospital architect and the medical directors of the hospitals he designed for, an interaction characterised by both collaboration and tension.  Adams also focuses, perhaps too much, on the seeming tension between a ‘modernist’ devotion to cutting edge technology and scientific planning apparent in plans and the interior medical spaces, and the historicist vocabulary which was widely used on the exterior and in lobbies and other social spaces, ‘disguising’, in Adams’ terms, the modernity of the buildings.  Judging from the reactions of contemporaries cited by Adams, they did not see the buildings in terms of tension and disguise, but judged their modernity, even from the exterior, according to subtle signs relating to scale, relative simplicity and materials used. That said, Adams’ detailed account of the processes by which the modern hospital came about offers a very welcome corrective to the approach to architectural history that judges modernity by purely formal standards.