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Of wandering doctors, cities, and humane hospitals

2010; Elsevier BV; Volume: 377; Issue: 9759 Linguagem: Inglês

10.1016/s0140-6736(10)62327-6

1474-547X

Marek H Dominiczak,

History of Medicine Studies

Legend has it that on the island of Kos in Greece, Hippocrates taught his pupils under a plane tree. There is something symbolic in the simplicity of such a depiction. It reminds one that doctors have often been wanderers, not bound to particular locations or buildings. They went out to see the sick in their own surroundings. Of course, the sick have always needed shelter and respite space. However, as more complex medical procedures developed, specific space was also required to perform them. Thus the respite and treatment strands converged on an architectural platform and, with time, led to the development of modern hospitals. The contemporary debate about what constitutes an optimum healing space to a large extent relates to the balance between the shelter-respite and the active treatment-related functions. This essay attempts to trace key historical developments of healing spaces. While early doctors were wanderers, spiritual healers often were not. A temple had been the dominant architectural form in human communities long before Hippocratic medicine, and indeed before the rise of European culture. In ancient Greece, healing was linked to worship: the centres of healing were the temples of the god of health Asklepios, known as Asklepeions. The largest of these were in Epidauros on the Greek mainland, and on the Hippocratic island of Kos. The monumental three-level temple on Kos stood on a hill facing the distant sea. Visitors were admitted at the lower level. They were subsequently taken to the higher terrace with open views, where they were to spend the night and be visited by Asklepios. The Kos Asklepeion very well illustrates the role of architecture as a framework for a healing ritual, and shows how spectacular blending with surrounding nature enhanced its impact on the “treated”. In the Middle Ages, Christianity, very much in the Graeco-Roman tradition, associated worship with monumental architecture. Caring for the sick and the destitute was part of the Christian message of charity. The early “hospitals” sheltered the poor, the pilgrims, and the abandoned children. For the sick, they were places of terminal care rather than of active treatment. They were appended to churches, and particularly to monasteries. The St John Hospital in Bruges founded in 1188 (probably by the city rather than the Church) was such a church-like building: by the 15th century it had three halls containing “patient” cubicles and the church space, which was an integral part of the hospital. The main altar painted by Hans Memling was visible from the wards. Prayer was a dominant part of the healing process. Subsequently, the ownership of more institutions became secular. In the Catholic city states, a city often owned hospitals jointly with the Church. In England, dissolution of the monasteries during the Reformation of 1536–41 forced a change of ownership. In London, St Bartholomew's Hospital (founded in 1123) and three others were granted by King Henry VIII to the City of London in 1546. City hospitals were often prominent public buildings. In Siena, the Santa Maria della Scala Hospital faces the cathedral across the main square. In Florence, the Foundling Hospital designed by Filippo Brunelleschi in 1419 is an outstanding example of renaissance architecture. The next major change in thinking about hospitals took place in the 18th century. It followed the Enlightenment emphasis on rationality, science, and nature. Later, during a reform of hospitals in France, their improvement amounted largely to the architectural redesign, particularly the introduction of pavilion structure, first in the Hôpital Lariboisiere, opened in Paris in 1854. This created a more open space that improved ventilation and access. Interestingly, the pavilion design later provided a framework for separate housing of emerging medical specialties. A true revolution in the concept of the hospital was caused by the accelerating progress of medical science in the late 18th and the 19th century. Hospital-based care maximised the medical experience by bringing together patients with similar conditions, facilitating statistical assessment, and—importantly—making clinical teaching possible. Thus, scholars entered hospitals, which became major sites of medical research on a trajectory rising until the late 20th century. A parallel, and complementary contribution to hospital design in the 19th century was the work of Florence Nightingale (1820–1910) and her nursing colleagues who reorganised hospital wards by applying the concepts of cleanliness and antisepsis, after spectacular results achieved at a field hospital in Scutari in 1854, during the Crimean War. The new science needed specialised spaces: laboratories gradually became part of hospitals, and the main dwelling places of scientists. This had a major influence on the architectural shape of hospitals—they became buildings with wards at the core, surrounded by increasingly complex support structures. In the early modernist period architecture gained increasing importance as a tool for social change. Architects such as Charles Edouard Jeanneret (1887–1965), better known as Le Corbusier, developed comprehensive plans for cities with new “division-of-function” layouts. Le Corbusier was fascinated by industrial buildings, processes, and mass production. He famously named his Unité d'Habitation (housing unit) in Marseille built in 1947–52 a “machine for living”. In addition, the “organic” architecture of Charles Rennie Mackintosh (1868–1928), Frank Lloyd Wright (1867–1959), and Antoni Gaudi (1852–1926) achieved new sophistication in manipulating textures and materials, and fusion of architecture with the natural environment. The emphasis on access to natural light and to surrounding nature became the hallmark of modernism—neutralising to an extent the effects of stern functionality. Within health care, this was particularly applicable to tuberculosis sanatoria built in the early 20th century, to allow patients ample access to fresh air, which was at that time regarded as a therapeutic measure. An extraordinary healing space implementing these principles was designed by a Finnish architect Alvar Aalto (1898–1976), in Paimio near Turku. His building was integrated with the surrounding forest but in addition Aalto applied the concept of total design that included the building, the interiors, and even small utensils. The hospital still functions as a health-care unit; it recently became a UNESCO World Heritage Site. In contrast to the sanatoria, the architecture of urban hospitals became increasingly determined by limited space and rising maintenance costs. The minimalist skyscraper, which turned out to be the most economical form of a building, was eventually widely used in hospital architecture. A “tower and podium” hospital evolved, with a ward tower and the podium containing support services. In these technically complex structures, the therapeutic functions, in a continuation of modernist zeal, had had unqualified priority, while the respite function withered. Architecturally, the undiluted functionality often created rather sinister structures, which the architect Markus Schaefer has said “neglected basic human needs”. Schaefer has suggested that “the hospital building stripped the patient of her privacy and individuality, the healing machine of her body”. Hospital space became increasingly perceived by patients and visitors as overwhelming, incomprehensible, and even threatening. Retrospectively, it was an astonishing lack of cultural balance. One could argue that the neglect of humane aspects of hospitals had roots in the rather insensitive nature of modernist science. One also wonders whether the post-Flexnerian, strongly focused view of medical science that became a mantra of medical education in the 20th century had an effect here. Or was it the disengagement of the arts and humanities from the medical landscape? The end of the 20th century saw some change, with increasing emphasis on individual rights and the contextualisation of medicine. These ideas influenced the design of a new generation of hospital spaces—all in the context of consumer culture and aesthetics. Also at that time, an application of scientific method to hospital architecture emerged in the form of evidence-based design. A seminal paper by R S Ulrich, published in Science in 1984, showed that access to natural light improves patients' recovery after surgery. There is now a substantial body of evidence that relates aspects of design to outcomes such as patient safety, infections, medical errors, falls, pain, sleep, depression, and length of hospital stay. Thus, in the context of individual rights, privacy, openness, and also aesthetics sparked by consumerism, architecture returns again to a prominent role: it becomes an advocate of cultural trends, which require an adjustment of architectural spaces beyond their functionality. Openness and clarity of structure become paramount for a hospital, not only from a functional but also from a cultural point of view. The challenge is to achieve this in a sustainable way while also allowing for future morphing of hospital spaces in response to medical science-driven requirements. There is a serious cultural role for a health-care facility in the contemporary world. A modern hospital can potentially enhance inclusiveness and social cohesion. The Philips Index: America's Health and Well-Being Report 2010 has shown that inhabitants rank the access to local hospitals as the most important factor related to wellbeing after safety and crime rate. The quality of health care was also a factor in the recent international Livable Cities survey—therefore it has an impact on the global “status” of cities, their attractiveness, and consequent investment prospects. What about the medical world? Since hospital spaces have both a functional and cultural meaning, they deserve more mention in medical education. At the University of Glasgow Medical School we have recently introduced an interdisciplinary teaching module on hospital spaces as part of the medical humanities teaching programme. Doctors started as wanderers—however, today, many wander no more. And they need to be aware of their dwellings. This essay is based on the Presidential Address I gave to the Royal Medico-Chirurgical Society of Glasgow in October, 2010.