Adams, Annmarie. 2008. Medicine By Design: The Architect and the Modern Hospital

Barbara M. Gravinese
Memorial University of Newfoundland

Review of Adams, Annmarie. 2008. Medicine By Design: The Architect and the Modern Hospital. Minneapolis, MN: University of Minnesota Press.
Pp. 240, black and white illustrations, endnotes, bibliography, paper, ISBN 081665114-0, $28.95.

1 In today’s world, design refers as often to biomedical engineering as it does to aesthetics. It may be said that Annmarie Adams has combined these two interpretations in the approach she has taken with her recently published Medicine by Design: The Architect and the Modern Hospital. For Adams, buildings and architecture function as social agents and in this book that concept is applied specifically to the hospital building.

2 Using Montreal’s old Royal Victoria Hospital (RVH) as her major point of reference—though not her only material source—Adams suggests that as a special building type, the hospital has played a major role in the development of modern medicine. She invites the reader to reflect on how architectural features give expression to, and help form, cultural attitudes that reinforce and solidify gender roles and relationships, as well as class distinctions. Adams posits that the separation of space, including living quarters for nurses and resident doctors, for example, reflected the social mores of the day, just as separate entrances for the poor and the wealthy reinforced class distinctions (36). To illustrate the relationship between hospital design and 20th-century medicine, Adams considers the impact of construction materials, light, space and the movement of air on patient care, workspaces and living quarters for medical personnel (10, 17, 78, 84, 113).

3 Through five chapters, Medicine by Design examines the roles played by patients, nurses, doctors and architects in the design of the early 20th-century hospital. Chapter 1 positions the study in 1893, the year the Royal Victoria Hospital was built. Adams presents an intimate view of the hospital as an urban character in a narrative that highlights the Royal Victoria Hospital’s multifaceted role in health care, staff housing and as a tourist attraction. At the same time, she discusses in detail the interconnections between the architectural features of the pavilion-plan hospital and emerging trends in medicine. Chapter 2 focuses on the patient as it examines the intersections between hospital spaces and patient care. The advent of germ theory and the manner in which it altered patient care and facility requirements—bringing sinks and sterilization methods into surgical suites and milk pasteurization into food services—is one example of how early 20th-century hospital design and new understandings of disease complemented each another.

4 The nurse is featured in chapter 3. Here, Adams considers the role of the nurse from numerous perspectives, including training and staffing. Among other issues, she explores how hospital design supported the interaction between nurses and patients, as well as between nurses and physicians. Contrasting the physical space of the nurse to that of the resident physician, Adams points to how the living and working quarters of each reflected their different social status, both in medicine and society.

5 Chapter 4 outlines the development of the professional relationship between the doctor and the architect. By the late 19th century the anonymous builder of buildings had become a professional—an architect, schooled and trained at prestigious institutions, often of prominent reputation, paving the way for architect-specialists, such as Henry Saxon Snell, Edward Fletcher Stevens and Fredrick Lee. In the case of the Royal Victoria Hospital, Snell designed the original hospital, while Stevens and Lee developed the plans for one of the later additions to the RVH.

6 It is Stevens whose career is most examined here. He is a professional who crosses the boundaries of architecture into the medical field. Adams discusses Stevens’s career and his professional presentation as an architectural specialist within contemporary medicine. Describing him as a person steeped in medical routines and practices, she illustrates how dynamic relationships between doctors and architects were instrumental in the design of the early 20th-century hospital.

7 Adams’s discourse describes the Stevens and Lee pavilion-styled addition as an architectural tour de force, built at a pivotal time in the changing social role of the hospital, from respite for the poor to exclusive retreat and treatment center for the middle class and wealthy patron (xxi, 40-43). Though Snell, Stevens and Lee are not the only architects mentioned, and the Royal Victoria not her only architectural example, Adams uses the exterior attributes and the internal logic of the Royal Victoria and its architects in various case studies to illustrate relevant points throughout this text (xix-xx). Ever aware of its functional life-span, her observations of the hospital’s physical changes over time are evocative of the growth stages of a living organism. “The ward itself was a medical instrument in which the patient could be carefully positioned in space,” Adams writes, a prerequisite eventually becoming less popular as acceptance of “germ theory” grew in the late 19th century (10).

8 The book’s fifth and final chapter, “Modernisms,” zeros in on the advent of modern-ist aesthetics and technology and its influences on hospital architecture. Her final section, a coda, succinctly emphasizes hospital architects and health care professionals, renovators and preservationists, city planners and governmental officials as power brokers and partners in “medical reasoning” (130), an awareness that is useful for today’s health care issues.

9 Medicine by Design will interest both the scholar and the general reader open to the idea of a dialogue with architecture from the inside out. As complex as the text is, it is well written and engaging. The book’s in-depth introduction, detailed endnotes and a seven page bibliography support the text and provide extensive information for further reading. Adams has made a strong argument for the built environment as a reflection of culture that continues to speak to the culture that built it; buildings serve as monuments to ideologies in space and time. This reviewer highly recommends Medicine by Design as an intriguing read for scholars, armchair professionals and students of architecture, the social sciences, city planning, medicine, health care and history. It is also an important contribution to postmodern material culture scholarship, as it unabashedly dissects personal and social agendas integral to the process of the built environment. This text asks important questions of commonly held cultural assumptions, particularly of institutionalized and hierarchical relationships as they continue to exist between social organizations of architecture, city planning and healthcare.

10 In the late 1990s, the Royal Victoria Hospital— fondly known in Quebec as Old Vic—merged with other Montreal hospitals to form the McGill University Health Centre.1

11 The building no longer functions as a medical facility but survives today as a renovated, historic landmark, a remnant of the past that represents a place where European aesthetics met New World pragmatism.


1 . Accessed 20 October 2008.