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

Just as Le Corbusier considered a house a machine for living in, so he envisioned a hospital as a carefully controlled machine for healing in. Le Corbusier's influential but unbuilt Venice Hospital (1965) took seriously the idea that proper cybernetic design, network programming, and automation could transform "a machine for healing into a hospital for life." Jeanne Kisacky's masterful survey of American hospital design between the end of the Civil War and the beginning of the Second World War shows that Le Corbusier's insight had been anticipated and put into practice by several previous generations of hospital designers. Moreover, by considering the hospital functionally rather than aesthetically, as a series of choices about how to incorporate the latest medical theories into practical design, Kisacky provides an architectural history that draws upon and contributes to the history of medicine in a way few other studies of the built environment of health care have done.

A close parallel would be a history of the factory during the same period, with its emphasis on how architecture reflected and reinforced innovations in scientific management, plant layout, labor organization, standardization, and cost efficiency within a highly contested space where the "one best way" was never certain or final. Kisacky explicitly considers the modern hospital as a kind of factory for healing, first as a machine à guérir, a space that would heal patients by controlling such environmental factors as ventilation, temperature, and exposure to sunlight, later as a "sorting machine" (p. 163) that could place patients and staff into appropriate categories and spaces for diagnosis, therapy, research, and training, and finally "the vertical hospital as an attractive factory" (chap. 5) in the interwar years, a space where control of information would be as essential as access to the latest medical technology. Perhaps the most intriguing example of hospital as factory is Henry Ford Hospital (1920) by architect Albert Kahn, better known for his automotive factories. Designed as a deliberate experiment in "Fordist" medicine and staffed largely with physicians recruited from Johns Hopkins, it's probably worth a monograph of its own. Like the author of any good factory study, Kisacky pays attention to workers, nurses, and technicians as well as physicians, and to how changing architectural prescriptions affected where and how (and how well) they did their jobs

Interpreting changing medical theory and practice in architectural terms has never been a straightforward proposition. As Kisacky details in her discussion of germ theory and hospital design, controlling contagion could be done by in very different ways. Johns Hopkins Hospital (1889) chose a conservative pavilion design, then modified it with the most up-to-date ventilating and heating systems that invisibly isolated the patients on a single ward from one another by the careful control of airflow around each bed. Its designers also experimented with a number of variations on the pavilion theme—octagonal wards, isolation wards, even tents—intended as closely observed experiments in best practice. New York Hospital (1877) took the opposite approach, building up (an unprecedented seven stories) instead of out, and relying on antiseptic practice rather than isolation to create a "germ-proof" environment. That meant increased attention to stronger disinfectants and easily cleaned surfaces, improved laundry and sterilization equipment, modern plumbing, and mechanical ventilation and filtration with separate exhausts for easily contaminated areas such as pathology and the morgue. Opening up the hospital's circulatory systems, it turns out, can be as revealing as one of Vesalius's anatomical illustrations.

Kisacky contrasts antiseptic and aseptic design, notably in the spaces most vulnerable to infection, the operating room and the maternity ward. Extending the evolutionary taxonomy of surgical spaces proposed by Annmarie Adams and Thomas Schlich—from operating theaters to surgical suites to operating rooms—Kisacky shows that "control" was never simply about surgery itself but also about how people and supplies...