Rise of the Modern Hospital: An Architectural History of Health and Healing, 1870–1940 by Jeanne Kisacky (review)

Jeanne Kisacky's closely argued and thoroughly researched study of American hospital design reaches back before the chronological range of her title into the eighteenth century, and suggests ways of understanding hospital buildings up to the present day. It thus serves as a pendant to Carla Yanni's equally ambitious 2007 account of American asylum building.¹ Like Yanni's book, Kisacky's is thoroughly interdisciplinary and grounded in a nuanced understanding of the history of hospital-based medical practice. In lucid and engaging prose, accompanied by extensive and well-deployed illustrations, including many floor plans, the author traces a shift from the idea of the hospital building as therapeutic in itself to the notion of the hospital as a tool serving the medical and social practices within it. But this is no straightforward teleology: both models of the hospital are presented with an awareness of their inner contradictions (in theory and practice). The process of change is also usefully nuanced; there is no eureka moment of transformation, and no direct correspondence drawn between medical advances and architectural form. This is an account involving multiple players, competing interests, and forces of both innovation and conservatism. Alongside medicine, multiple other factors are brought into play, including professional competition and specialization (among doctors and among architects), commercial imperatives, class, and social control.

Central to Kisacky's account is the shift over time from the dominance of the pavilion-ward model of hospital planning to the dense multistorey and multifunctional hospital type. The first, based on Florence Nightingale's widely disseminated 1863 guidelines, was a "pneumatic machine" for healing patients, meticulously controlling the interaction of inside and outside environments to expose patients to copious amounts of light and fresh, moving air. This was the idea of the hospital building – the size, shape, and placement of patient wards, the placement of windows and beds, ducts, and ventilation technology – as itself curative. But Kisacky implicitly reveals that this idea was rooted in the long-standing fear that hospitals were in fact one of the greatest impediments to good health. Assembling large groups of sick and possibly infectious people in one place frequently made sick people more sick – the scourge of "hospital disease," of the infection of patients after entering the hospital, accompanied the group treatment of patients from its beginning. Because medical experts considered disease to be spread by air, effective ventilation became the central factor governing design decisions and led to the international dominance of Nightingale's system from the 1860s to the end of the nineteenth century. As Kisacky points out, the system of separating categories of patients into widely spaced ventilated wards on open sites, within which patients occupied beds separated by "walls of air" created by cross-ventilation, was accompanied by a rigorous attention to hygiene manifested in white walls, hard cleanable surfaces, and minimal decoration.

Kisacky demonstrates the stubborn persistence of the pavilion-ward plan for several decades after the widespread acceptance of Joseph Lister's and Robert Koch's discoveries in the 1860s and 1870s that disease was transmitted not by miasmas but rather by direct physical contact with microorganisms (germs). She also offers a carefully argued and convincing explanation for the plan's persistence. It was not a matter of "architectural inertia" but could instead be linked to early understandings of germ theory, which continued to stress the role of air in the transmission of germs from one patient to another. In that context, ventilation was still seen as having a vital role to play, and hygiene became even more important. The hospital under early germ theory continued to spread out over extensive open sites, providing multiple free-standing cross-ventilated wards – the most well known example was the Johns Hopkins Hospital of 1875–85. The smooth washable surfaces were made even more so, with tiles and sealed plaster replacing wood, and every effort...