Considered as a logical next step from healthy house, have hospitals been catalysts in the development of modern medicine? Or have they, as many architectural and medical historians had assumed, simply been passive reflections of medical innovation? (Adams, 2008)
Buildings are never neutral: they define relationships and organise our lives. In numerous ways hospitals reflect the categories of society, by showing age and gender differentiation, for example, and by articulating wards in accordance with specialisms and diseases. Miasma theory which designated 'bad air' as a cause of disease resulted in great emphasis on cross-ventilation, because it was only in the 1870s that Pasteur established the existence of microbes, and before that what one could smell was self-evidently dangerous. However, in modern hospitals air-conditioning has taken over, and whole buildings are planned for ease of servicing, to the detriment of way-finding. Until the mid 19th century the chapel had a hierarchically dominant role because God was still in the picture and many people died. Today most people die in hospital but we don't acknowledge it because is it supposed to be a healing place. In the 19th century operating theatres were just that, with lots of dirty people in ranks of seats looking on, now it is one of the most tightly defined enclaves of modern life with stringent barriers and ritual cleansing. In the 1920s tuberculosis was a major killer and without antibiotics was difficult to cure, but UV light in sunlight killed the bacillus, so patients were exposed to the open air in buildings like Aalto's Paimio, and this idea was reflected in many other buildings of the period, such as open-air schools. For a good history of the building type see Thompson and Goldin 1975, and on miasma theory and birth Ann-Marie Adams. There will be a chapter in hospitals in my forthcoming book Architecture and Ritual.
I do agree with gregory.
Most of the time, whenever hospital want to modernized it's equipment, it will change the structure. Sometimes, after 10 years, most advanced hospital would not be as advanced as it used to be.
It seems reasonable to think new advancements and medical innovations have been changing the architectural design of a hospital but perhaps in modern rich cities. Either the medical equipments and their standards which can directly affect the size of the different spaces or the new scientific findings which affects the lay out and functions of spaces in a hospital. So depending on the environment,it can vary a lot, for example an advanced hospital in a big city comparing to a one in a remote villages or a poor area
Basically, Hospital is the place where you experience and utilize the services rendered by the medical innovations. Apart from hospitals which includes the diagnostic centers also doesnt have any-other locations to be utilized. So irrespective of conventional medicine or modern medicine the hospital will be the only catalyst center for medicine, because both the success and failure of the components of medicine will be identified, evaluated and treated in hospitals excluding the technical aspects of equipment and core biology of pathologies which will be dealt at research and development labs. So R&D labs do support for the catalytic activity of hospital for medicine. Unless the R&D lab come s forward with an innovation (both diagnostic and therapeutic), the hospital cannot analyze it in real life scenario.
I conclude that the for technical/biological innovation the R&D labs are catalyst centers and for application/utilization of innovation the hospitals are the catalyst centers. Both Hospitals and R&D labs represent the innovations in modern medicine.
Hospitals must ensure to the community maximal performance with minimal expenses. Many chiefs of operating hospital units have thus become accountants rather than men of science. Because that's what the politicians and rulers are asking. Therefore, in some cases to have simply been passive reflections of medical innovation is akready an excellent result.
This does not mean that research and innovation should be forgotten. Each operator should be open and contribute to the development of modern medicine. Each with its preparation, creativity, spirit of observation and the availability of resources. The time must be often subtracted from the personal need. Exception: working havens. In Italy: hospitals supported by religious institutions.
No, hospitals are not. In many cases even the prescription is driven with the knowledge of medical representatives of the pharmaceutical companies.
I agree in general with Gregory. In the beginning hospitals have been the number one development and research center for modern medicine. And most important innovations came from careful clinical studies. I just want to mention reconstructve surgery, hygiene, or the establishement of whole new medical disciplines like urology, dermatology and others.
Of course, since hospital have raised in many places and with variable budget times have changed. Small hospitals with very limited budgets will usually not be the motor of medical innovations. If they achieve the level of beeing a reflection of achievements of modern medicine this is important as well.
Even if nowadays most hospitals will not be the developer of new drugs or new (robotic) surgery equipment, they still play a major role in critical evaluation of developments offered by various inductrial companies.
It has become more and more important, that hospital researcher seek cooperation - with other medical disciplines and outside medicine. Hospitals also play an important role in education of new generations of doctors and nurses.
In conclusion, the answer to your question is YES, but the content and the setting is changing during time.
Whether hospitals aid or merely reflect medical innovation entirely depends on hospital administration. If the chief executive is a government bureaucrat, then the hospital reflects the government's attitude toward research, varying by country. If the chief executive is a medical man involved in research, the hospital will most likely aid in medical research. If the chief executive is a philanthropist, hospital practices in research will stem from the promotion of fund-raising.
Dear Nelson,
Dear All,
I have thought always, a philanthropist main aim is to help suffering people. Of course, I am an ignorant layman who has no idea what modern medicine is? What is the objective of modern medicine?
Interesting question but with controversial answer probably in most of the countries. Especially in Bulgaria, the answer can be "Yes, with no doubt the hospitals are catalysts", but only few of them, especially one or two private with financial support, based not only on NHIF, but external, and some of the public university hospitals.
Dear Lona,
The question is of remarkable interest. By my viewpoint of gastroenterologist the answer can be different in relationship to different countries and to different dimension of hospital. In Italy, the public hospitals and the big private institution of long tradition (secular and religious) have been catalysts for the modern medicine through the activities, the competences and the professional updating of several operators, especially “in Internet era”. Such matter cannot be extended to the private and “little” hospitals, more inclined and interested to logic of business and profit
Well I think the answer is 'yes' - the design and the space of a healing center should look to advance well-being at every level. For example, consider the 'placebo' effect -- what exactly is that, how does it work? There's no denying that it exists -- I've seen in many times in operation in clinical practice. I think the structure, the environment, the 'space' of healing can be optimized through the diligent work of architects like you. So I do encourage continued efforts to optimize these healing spaces. I'm reminded actually of the 'Planetree' model - have you heard of that? http://planetree.org
My small hospital in Connecticut, USA doesn't exactly follow that model - but we do have large windows in every patient room, and even a waterfall. Flowing water tends to bring peace to the mind - and it's important to have a still, peaceful mind when fighting physically for one's life...
In contrast, I think of some hospitals I've practiced in, like places in Metro Manila, where more than one patient is crammed into a bed in difficult conditions. It's an incredible contrast between rich and poor. It would be of interest 'what' you architects could do with indigent hospitals in the developing world. Some 'basic' improvements like adding good ventilation and sunlight would even help cut down on some of the infectious risks -like tuberculosis. That germ dies when exposed to sunlight, and cannot transmit well in an airy environment -- hence the 'sanitarium' of ages past.
Good luck!
First, it depends on what one defines as a hospital. Historically, these have ranged from little more than a place of quarantine to facilities equipped with the best medical minds and best medical equipment and pharmacies available at the time.
Second, as others have suggested the degree of support to a hospital by its sponsor (public or private) is crucial in both financial and policy terms. To what extent to practitioners in hospitals have autonomy to innovate, or are there punishments for departing from rigid policy? The rapid evolution of medical specialties/knowledge and financial cost of specialized equipment are more likely now than ever to make the well-funded hospitals the centers of innovation where clusters of innovative practitioners can be associated in research hospitals. So there is an ever higher threshold to innovation.
Third, "best medical minds" needs explication. It is not a question of the credentials of the physicians -- although this may not be totally unrelated. It is more related to the creativity and knowledge base of the physician. This certainly goes back to Abu Sina. But we are in an era now that largely beyond anecdotal medicine, one based on careful study design. That said, innovations like Gawande's checklists that any hospital can invoke have important effects on patient outcomes.
I am not in the medical field so my comments come from a layman’s perspective for the Ontario, Canada medical environment. Based on our system, it is both at the same time. Go down University Avenue in Toronto, and every single hospital is involved in advanced research programs from stem cell technologies to pediatric transplant programs.
But go north 100 kilometers to Orangeville, Ontario, and the hospital is about providing care and surgery. While the information they gather during treatments may be used in other people’s research, the hospitals outside on major city centers are more about treating the patient. Read through their web site and you see; cardiac care, chemotherapy, pediatrics and palliative care.
When there was concern about a possible eye cancer, my wife went from family doctor, to specialist, to local hospital for tests, to Princess Margaret in Toronto, who specialize in research and treatment of eye cancers and other ocular diseases.
I think one of the advantages of our system in Ontario is that doctors can choose a path to either work in a research hospital, helping make advances in the field of their interest, or they can choose to work helping make individual lives better by their care of patients. Both are admirable options and I am glad we have both types of hospitals here.
Brenda: Yes, you are absolutely right. Particularly in this age of specialization, nurses and all other support specialists are crucial. But good nursing care and practice have been important from at least Florence Nightingale to present, as someone else mentioned too.
Thank you Ierardi for sharing the interesting point of view. It sounds to me you have experienced lots of practical challenges by the politicians and rulers. I agree with you that is absolutely one of the important factors every architect should be aware of when designing. I also believe It is sometimes an obstacle for creation and the reason leads to "passive reflections of medical innovation".
So Netra, do you meant that hospitals are neither catalysts in the development of modern medicine nor being passive reflections of medical innovation? Well that seems an interesting point of view to me. Adrian Forty-architectural historian-refutes the argument put forward by historians of medicine that advances in medical technology change hospital form.
However, I ialso found the idea of Sociologist Lindsay Prior fantastic as he believes that more attention should be paid to social context of hospital design. Emphasising the design as a passive receptor of medical innovation by "The acceptance of germ theory found its initial expression in the sitting and design of the operating theatre and the laboratory, but from there it moved outward and into the wards". He also claims " the architecture of hospital is, therefore, inextricably bound up with the forms of medical theorising and medical practise which were operant at the hour of their construction and, what is more, all subsequent modifications to hospital design can be seen as a product of alteration in medical discourse". Much of his argument was presumably aimed at Nilolaus Pevsner, who had suggested that hospital design was the product of architect's creativity.
Conclusion, to my limited knowledge, I incline to the idea hospitals are the combination of the innovation of medicine and architect's creativity. Still on the go to figure out how and where architecture and medicine innovation intersect in designing hospitals.
Buildings are never neutral: they define relationships and organise our lives. In numerous ways hospitals reflect the categories of society, by showing age and gender differentiation, for example, and by articulating wards in accordance with specialisms and diseases. Miasma theory which designated 'bad air' as a cause of disease resulted in great emphasis on cross-ventilation, because it was only in the 1870s that Pasteur established the existence of microbes, and before that what one could smell was self-evidently dangerous. However, in modern hospitals air-conditioning has taken over, and whole buildings are planned for ease of servicing, to the detriment of way-finding. Until the mid 19th century the chapel had a hierarchically dominant role because God was still in the picture and many people died. Today most people die in hospital but we don't acknowledge it because is it supposed to be a healing place. In the 19th century operating theatres were just that, with lots of dirty people in ranks of seats looking on, now it is one of the most tightly defined enclaves of modern life with stringent barriers and ritual cleansing. In the 1920s tuberculosis was a major killer and without antibiotics was difficult to cure, but UV light in sunlight killed the bacillus, so patients were exposed to the open air in buildings like Aalto's Paimio, and this idea was reflected in many other buildings of the period, such as open-air schools. For a good history of the building type see Thompson and Goldin 1975, and on miasma theory and birth Ann-Marie Adams. There will be a chapter in hospitals in my forthcoming book Architecture and Ritual.
Brenda: Thanks for the reminder. In this global age where epidemics can spread so quickly, nurses are both organizers and administrators of infection control in hospitals. This is how ebola-like situations can be sequestered and quarantined inside hospitals while minimizing risks to other patients.
Each hospital has its own timing to go through modernity. What I observed at the hospital of Geneva at the end of the 18e century is that modernity came through different ways 1) physicians beginning to strength their corporation became to struggle hardly against the alternative practitionners which were quite present in the hospital 2) Directors of the hospital, who were not physicians but very interested in medical sciences push the physicians to be more present inside the institution 3) Clinical trials has been undertaken, due to syphilis which was a great problem of public health. In Geneva, one of the surgeon of the hospital, impulsed by the directors, made such a trial in 1761. Here it was due to the personnality of one surgeon. Modernity is quite a complex concept. It depends on many different actors, implicitely or explicitely. It runs on a timing which is quite long.
As an historian of technology (and not a medical historian) I would like to point at the role of technology in medicine and its relation with the modern hospital.
In my research about transitions in (Dutch) healthcare in the 20th century I encountered an interesting (propaganda) movie from the early 1930-s on the internet: A day in the life of Sheffield Royal Hospital (UK). I give you some of my observations that are maybe interesting to you:
"Technology plays an important role in the movie. Not surprisingly as it was a ‘resource’ for professionalizing and specializing medicine. (Blume, 1992; Stanton, 1999) In 1949 its importance in the Netherlands was noticed: Technology ‘created the possibility to record what long was un-recordable; […] gave chances to determine what seemed un-determinable; [made] accessible [those] parts of the body that were presumed un-accessible during life." (Doesschate, n.d.; Reiser, 1984)
Along with technology, the modern hospital entered the medical domain. It became the geographical locus of medical care and cure, the place where agents of healthcare, patients and technology met. Medical technology centralized healthcare, and specialization allowed for routine, standardized procedures and a continuous monitoring of patients (Howell, 1995; Stanton, 1999). In hospitals "seperate medical interventions of diverse people" were linked through medical records (Reiser, 1984). An inextricable bound between technology, the hospital and medical records was established after WW II."
My conclusion would be that the modern hospital facilitated a transition in Western healthcare in the 1920-s/'30-s: cure-, technology- and specialization driven. This regime however became contested since the 1970's.
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