Book Review: Medicine by design: The architect and the modern hospital, 1893-1943
Medicine by design: The architect and the modern hospital, 1893-1943, Annmarie Adams, Minneapolis, MN: University of Minnesota Press, 2008
Annmarie Adams‘ methodological position treats buildings and architecture as social agents, not simply as receptive canvases of human intentionality. Taking this attitude towards hospitals, she uses Montreal’s Royal Victoria Hospital (RVH) in the period 1893-1943 as her main historical source and reference point, anchoring a story touching on class, gender, geography, professionalism, domesticity, medicine, and architecture itself.
Recent intellectual trends may predispose us to expect a story about spaces which reinscribe professional and scientific authority, subjecting passive patients to a medical gaze, but Adams’ work disables such easy explanations. Beginning with the question
Were hospitals catalysts in the development of modern medicine? Or were they…simply passive reflections of medical innovation?” (p. xvii),
Adams sides with the former question, eschewing any reductionist account of hospital architecture and the interests served.
The architectural history of the RVH and other Canadian hospitals of the time was not the expression of a monolithic authority. Even though Edward Stevens, “North America’s top hospital architect” (p. 95), could mandate natural light for surgical spaces and advocate space for hydrotherapy in his building plans, his impositions and attitudes met with resistance from surgeons, administrative hospital bodies, and other architects. The architecture of these hospitals is, in places, the product of a particular vision and, at other places, the outcome of political negotiations.
On one hand, the RVH’s architecture affirmed class-based distinctions, via separate entrances for paying patients and for the poor. Higher rooms were reserved for paying patients, so there was a correlation of elevation with status. On the other hand, architects designed nurses’ residences according to a romanticization of the domestic, and to control students’ behaviours, but also to appeal to scientific legitimacy. The resultant sequestered spaces were simultaneously a concession to existing gender relations and also a space for the development of professional identity and autonomy.
Adams’ book is laudable for asking how the hospital sustained and made intelligible these social relations. Hospitals, like other spaces, are not simply the expression of archetypal social forces preexisting them. It is the building, in part, which sustains social relations and makes them part of experience. In the case of the nursing students, the residential space made the practice of gender norms possible; it was not merely an aftereffect or document of those norms.
However, methodological issues arise. It is not clear at which points Adams gives the hospital’s architecture some autonomy or causal primacy. On one hand, Adams argues “the presence of thousands of pregnant women…had a profound impact on the development of hospital architecture” (p. 42) but also that the domestic connotations of maternity lounges moderated wariness around the pathologization of childbirth. Did the medicalization of childbirth prompt the development of maternity wards and space for obstetrics, or was there a dialectical operation occurring? To what extent did those new medical spaces produce a change in attitudes towards childbirth, and to what extent did they reflect social attitudes generated elsewhere? Also, while Adams uses textual sources alongside architectural plans, photographs, and buildings, we must ask whether written histories explain architectural outcomes or if architecture itself can explain social processes. What can we deduce from the changing architecture of operating theatres, for example, without employing other sources to support our conclusions?
These are questions, not indictments, for the author is quite clear about using multiple sources, and detailing the complexity of social and architectural interaction. Adams’ book is valuable for alerting us to the potential of treating hospital architecture itself as historical source; the book is successful in taking such places as focal points for a historical narrative.
Reviewed by: Gregory Bowden, University of Alberta, Canada.
-Ondine