Medicine by Design, The Architect and the Modern Hospital, 1893–1943 (review)

Medicine by Design focuses on the building and development of the Royal Victoria Hospital in Montreal from 1893 to 1943, a period that includes World War I and the interwar years. To this specific context of a single place over time, Professor Annmarie Adams brings a synthetic methodology, investigating the broadest set of cultural artifacts (including the buildings themselves, their plans, historic postcards and photographs, and popular press advertisements) as well as written texts. The book is not a chronology but a set of five linked essays that use the evidence of material culture to uncover the influence on hospital design of “Patients,” “Nurses,” and “Architects and Doctors” (the titles of three of the chapters).

Eighteen ninety-three was the year the much-acclaimed Royal Victoria Hospital (designed by Henry Saxon Snell) opened on the slopes of Mount Royal overlooking Montreal. Fifty years later, in 1943, Edward F. Stevens, partner of the firm of Stevens and Lee (experts in hospital design and architects of two additional buildings to the same hospital complex, the Ross Memorial Pavilion [1916] and the Maternity Hospital [1926]) retired. Within these fifty years, significant shifts happened in hospital architecture. These changes have been typically attributed to developments in medical technology, but in Medicine by Design, Professor Adams challenges that assumption and examines the influence on hospital design by architects with expertise, factors of social class, and cultural attitudes about gender.

During these fifty years, hospital architecture became a specialty. Hospitals went from being designed like other large civic institutions, such as prisons and schools, where plan and exterior were equally important, to being designed specifically as hospitals, where the organization of the floor plan became the primary focus. Architects went from being generalists for civic institutions to being hospital specialists who worked with medical experts and traveled in Canada, the United States, and Europe to gain additional exposure to contemporary hospital design. The two generations of architects featured in this book, Henry Saxon Snell and Edward Fletcher Stevens, built their reputations on hospital work. They increased their expertise by traveling in North America as well as in Europe, studying contemporary hospitals there. Snell began his career in Europe, and Stevens traveled there and brought back lantern slides to use in both winning commissions and in developing designs. They worked with physicians and medical experts as coauthors and consultants to understand what was needed in a modern hospital. Stevens developed his expertise from decades of close observation, writing of the value of “a long series of visits, oft repeated, to institutions known to be satisfactory” (Adams, quoting Stevens, 102). Both architects wrote books and articles, gave conference presentations on “best practices” for hospital design, and often featured their own designs. Their interest and focus on hospitals increased their expertise and snowballed into winning more commissions, further augmenting their knowledge. This kind of reflective practice remains a model today for architecture specialization.

Over this period, hospital plans changed from pavilion plans with rectangular open wards to “block plans” with double-loaded corridors and isolated patient rooms on each side. The medical explanation for this shift lies with the acceptance of the theory that disease is transmitted by germs, so isolating patients is better than having them housed in the same space. The pavilion plan had developed at the time of the miasma theory of disease, where disease was believed to exist in putrid air, so easily supervised, open, narrow wards with high ceilings were carefully spaced to maximize light and air. Professor Adams contributes to scholarship that is debunking this simplistic interpretation. She shows evidence that the pavilion plan persisted well after germ theory was accepted and develops arguments that as hospitals changed from places to care for the indigent to places to cure the sick, they needed to reach out to the rich and middle classes. These new clients...