HISTORY OF HOSPITAL PLANNING

 The hospital as an institution offering care to those who need it is of great antiquity. The
modern word is derived from the Latin hospes (“host”), which is also the root for the words ‘hotel’,
‘hospice’, and ‘hospitality’. The earliest examples approximating the institutions we call hospitals,
however, were the Egyptian temples of 4000 years ago. The association of religion and medicine was
a natural one in many ancient cultures.

 Originating in the time of the matriarchal goddess religions, when the cyclical process of
nature and women’s ability to give birth were revered, the relationship between the midwife and the
woman giving birth was the first healer-patient relationship. In primitive societies those seen as
holding mystical powers came to acquire more formal ones. Thus healing and believing brought forth
the faith healer.

 Early knowledge was gained both from intuition, as well as from watching animals and then
passing on the accumulated knowledge down through the generations. Apart from primitive tools
there was no technology and medicine was based upon touch, comfort and belief.
The early Egyptians identified over 250 diseases and combined medicine with magic and
religion. As they developed the science of medicine, treatment and drugs, there was parallel
development in improvements to public hygiene and sanitation. The Babylonians further developed
medicine and records show that fees were charged for a healers services. Yet it was the Greeks who
gave us Hippocrates and the famous oath. Greek buildings used for medical care were still similar to
temples. The Greeks however viewed healthcare in a natural and totally holistic framework. The
Greeks assumed, as only natural, that healthcare treatment should include music, poetry, arts and
good cuisine. Temples dedicated to Asclepius were noted for their cures.

 The idea of an institution created specifically to care for the sick appeared in Hindustan in the
third century B.C., and in first century Rome. In Hindustan, the king Asoka is credited with
establishing some 18 centers for treating the ill. There were physicians and a nursing staff, and the
expense was borne by the royal treasury. Hospital style institutions appeared in China in the first
millennium A.D., as part of a state supported care system, while in Rome there were special
institutions for slaves, gladiators, and soldiers.

 From about 500 BC to 475 AD the Romans assimilated medical cultures from the territories
that they inhabited. Generally, the Romans, as the Greeks, provided healthcare in the community.
The Roman hospital was built upon a military regime within a rigid institutional setting. Thus the early
example of what has become known as the medical model was indeed based upon the military
model, that is, the provision of care within an ordered and military setting.

 The early Christian era, between 1 and 500 AD brought the return of women in the role of
healers through the Church and convents. It was the Christian commitment to care for the sick, to
comfort the lonely, and to feed the hungry which motivated the prodigious growth of hospices,
orphanages, old age retreats and hospitals proper throughout the medieval world. The first Christian
Hospital was completed between 368 and 372 AD. During the chaos that followed the collapse of the
Roman Empire between 500 and 1000 AD, monasteries retained the teachings of the early Greek
texts. Monks used their knowledge of medicine and herbs to care for the sick and the term hospital
was synonymous with offering hospitality, i.e., refuge from the ravages of the outside world. Clarity of
form was lost during the medieval Christian period, and hospitals once again became
indistinguishable from medieval architectural forms.

 In the medieval west, as in the east, the church bore primary responsibility for developing
institutions of care. Among the hospitals built by it was the Hotel Dieu, founded by the Bishop of Paris
in the seventh century, which today is the oldest working hospital in existence. Hospital facilities
expanded radically from the eleventh through the fourteenth centuries. The Crusades were in part
responsible. The crusading orders built hospitals in Germany and throughout the Mediterranean
world. Royal and noble families also contributed to the growth. England’s first hospital was built at
York in 937 by Athelstan, a grandson of King Alfred the Great. In the twelfth and thirteenth centuries,
when Europe was in the grip of a vast leprosy epidemic, hundreds of leper asylums or leprosaria were
built. it has been estimated that in 1225 there were 19,000 leprosaria in Europe. As leprosy declined,
some of these leprosaria became hospitals. Thus the Hospital des Petits Maisons outside Paris which
began as a leprosaria was alter used for indigent syphilitics and mentally disordered pilgrims. When
the bubonic plague struck Europe in the fourteenth century, the leprosaria were the first plague
hospitals.

 During the seventh century, the rise of Islam led to the Muslim conquest of many countries.
Islam inherited a rich medical tradition, and by the ninth century it had established a sophisticated
medical system. Hospital complexes were constructed at Baghdad in the ninth and tenth centuries
which employed upto 25 staff physicians, which maintained separate wards for different conditions,
and which gave medical instruction. Thirty-four such hospitals have been identified in Muslim cities
from Mughal India to Spain. Islam, like Christianity, emphasized the community’s responsibility for
those who needed help.

 Byzantium’s political resurgence under the powerful Macedonian dynasty in the ninth and
tenth centuries brought further hospital construction. The famous Pantocrator, which was begun by
John II Comnenus in 1136 was built as part of a complex of buildings which included a sumptuous
church, tombs for the ruling dynasty, and a monastery. This hospital was the greatest achievement of
the long Byzantium tradition. The hospital comprised 50 rooms which were divided into 5
departments. There were 5 rooms for surgical cases, 8 for acute illnesses, 10 each for men and
women with various complaints, and 12 for gynecological cases. The remaining 5 were available for
miscellaneous use, including emergencies. Each department had a staff of two physicians, five
surgeons and two nurses or attendants. There were also an out-patient department for ambulatory
cases, a pharmacy, baths, a mill and a bakery.

 Later, in classical antiquity, the rational processes of thought were reflected in the plan form,
which gradually evolved a character of its own. Order and clarity became evident and clear patterns of
circulation were delineated and attention was paid to functional groupings. More scientific methods of
healing appeared throughout the Renaissance period, 1400 – 1700 Ad. This was also the time of
Michaelangelo and Leonardo da Vinci who saw the integration of art, invention and medicine.

 In England the traditional role of the Catholic Church in healing and medicine declined as
Henry VIII broke away from Rome. The closure of monasteries by him and the resulting loss of there
medical expertise was a spur to the development of the medical profession, which then developed
outside it’s religious origins. He encouraged and gave authority to physicians, granting the College of
Physicians a charter in 1518. The years 1550 to 1850 were the dark period of nursing. Women were
assigned nursing duty in lieu of a jail sentence. Many hospitals fell into decay, and insanitary
conditions, epidemics and diseases were common. The hospital was seen as a place to warehouse
the sick and dying and not necessarily a place for care and treatment.

 By the end of the sixteenth century, monarchs and municipalities had become the prime
movers in hospital development. In France, as in most continental European states, the central
government took responsibility. In 1656 the Cardinal Mazarin created the Hospital General in Paris.
These hospitals showed the evolution of the medieval concept of care into the secularized one of the
sixteenth and seventeenth centuries. Though much larger and administratively complex than their
medieval predecessors, these institutions were similar in that social functions were fundamental, while
treatment was of minor importance. A further change, however, was coming. Vesalian anatomy,
William Harvey’s circulation theory, and a growing interest in clinical medicine were giving hospitals a
new significance. It was there that the actual sick could be observed, that medical applications of
scientific discoveries could be made most conveniently, and that students could be taught. Bedside
observation and teaching began in 1626 at Leyden and Utrecht, won support from leading English
scientists including Sir Francis Bacon, and through the work of Hermann Boerhaave, the Leyden
clinician and one of Europe’s greatest teachers, gained a European following. Even so, the
transformation of the hospital into a medical institution was not complete for another century and a
half.

 Between 1700 and 1850 the foundations of the modern hospital system were established.
The number of hospitals increased, the quality of medical practice improved, specialization advanced,
and the emphasis shifted from care towards treatment and cure. The process was most rapid in
England, whose 18th century development was phenomenal, but by the middle of the 19th century
most European societies as well as the United States had established a basic hospital system. In the
American colonies the first hospital was founded in Pennsylvania in 1751, with Benjamin Franklin as a
Trustee. Throughout the entire period of development, two contrasting systems for planning and
financing hospitals appeared. In England and America, private funds and independent boards were
the norm. On the Continent, central governments and public funds led the way. The American
hospitals served a social need, but their staffing with trained physicians as both house physicians and
consultants showed an orientation from the beginning towards treatment and cure.

 The brilliance of French medical scientists both before and after the revolution was
unconnected with the state of hospitals or other institutions. At this time, hospital reformers, activated
by a humanitarian concern over the real suffering of those unfortunate enough to be hospitalized and
convinced that an enlightened age had the means to relieve it, began to agitate for changes. John
Howard, an English prison reformer who became interested in hospitals, was probably the person
who did the most to popularize reform ides on the Continent. He was particularly emphatic about the
need for cleanliness and fresh air to combat the deadly miasmic vapors which were thought to be
responsible for illness, infection, and high mortalities.

 Probably the most important 18th century Continental hospital was Vienna’s Allgemeine
Krankenhaus (general hospital) built by the order of the emperor Joseph II in 1784. This hospital
epitomized the Enlightenment absolutist’s approach to medical care and public health through
administrative centralization and rationalization of function. It also showed the growing conviction that
hospitals were primarily institutions for treating sick people, while its provision to accommodate both
the poor and paying patients struck a modern note. Vienna’s influence was also significant throughout
other parts of Europe, appearing in a series of 100- to 200-bed hospitals built between 1784 and
1850.

 The combination of further scientific study and epidemics such as cholera in the United States
from 1830 to 1850 created a demand for more hospitals. As hospitals grew larger, so the incidence of
cross-infection became greater. A big turning point for health-care was the Crimean War. In Crimea,
Florence Nightingale gained fame for her nursing skills. At the end of the war Nightingale became
committed to designing hospitals. She devised a series of concepts that had to do with light, air and
cleanliness. She understood the need to plan care buildings to avoid cross-infection. The dramatically
low mortalities in her temporary barracks at Scutari made her a nearly irrestible influence on
questions of hospital organization and architecture. She introduced a regime of greater cleanliness
and order and the now famous Nightingale ward, born out of the need for a stricter regime of care and
discipline, left an indelible mark on the subsequent planning of healthcare buildings.

 Both in the Crimean War and in the American Civil War, a need was recognized to improve
medical care through cleanliness, discipline and scientific rationality. Both sides built large temporary
military hospitals which were considered models of organization and further proof for the ‘fresh air’
thesis. Treatment on the battlefield became the generator for new models of care planning. Surgery
until then was always seen as a last resort. The outcome was invariably poor due to cross-infection
and pain must have been horrendous without proper anesthetic. Yet towards the end of the 19th
century, with Louis Pasteur’s and Joseph Lister’s understanding of living organisms and methods of
antiseptic, the surgeon came to the fore. As it became understood that surgery was best undertaken
in antiseptic conditions, so the importance of the hospital as the focus of healthcare treatment
became further established. X-ray technology, which developed first as a diagnostic tool, became a
form of therapy requiring special instrumentation and facilities; while advances in biochemistry
opened a wide variety of treatments and diagnostic tests which only a fully equipped laboratory could
perform. In much the same way that manufacturing technology shaped the factories and shops
necessary to its efficient use, medical technology influenced the development of the modern hospital.
The key dates may said to be:
  . 1846- The discovery of anesthetics, which spread throughout the Western world within a few
years.
  . 1866-9 – Lister’s use of carbolic sprays for antiseptic surgery, which by combating infection
enormously reduced the number of post-operative fatalities.
  . 1886 – Von Bergman’s introduction of aseptic techniques, the sterilizing of instruments and the
use of autoclaves.
. 1895 – Roentgen used X-rays as an aid to diagnosis. Instead of relying on their five senses,
doctors now had the possibility of confirmation in black and white. Laboratories similarly added a
new dimension to medicine and enormously extended the use of pharmaceuticals.

 Not until the late 18th and early 19th centuries was hospital planning treated on a functional
and scientific basis. Then the ‘pavilion’ type plan evolved, segregating patients into small groups and
ensuring natural light and ventilation. Two other factors led to this kind of planning. Fear of contagion
led to segmentation into increasingly isolated pavilions, and differentiation of the medical profession
led to the organization of many pavilions into specialty departments. The period from the turn of the
century to the present day has seen the architectural forms of hospitals change from low horizontal
pavilions to a vertical monoblock.

 With the discoveries of X-rays and radium, the diagnostic approach to healthcare became
bound to a building rather than being brought to the people. Technological advances accelerated
throughout the 20th century. Each bore the need for new equipment, with technology further
centralizing and emphasizing the place of the hospital as the main focus of medical skills.
After World War II, major factors influencing the evolution of hospitals in the US were primarily
internal in nature. Major design influences related to changes occurring within a particular hospitals
medical staff, or those produced by new treatment modalities and equipment. External forces played
a relatively minor role in influencing design, and the evolution of one hospitals facility was little
influenced by any other institution, except during periods of competitive action.
During the 1960’s, architectural firms in the US specializing in hospital design directed their
efforts to developing new programming techniques, applying systems theory to planning, and
updating departmental planning through functional analysis. The space age that flowered in the 1960s
was another turning point for hospital design. Electronic devices developed for NASA included CRTs
(cathode ray tubes) for monitors and imaging devices. With the 1970’s came several changes in the
health care system which shifted emphasis in hospital design. The most important factors influencing
the physical organization of the hospital were no longer internal changes but external constraints.
Important forces of change were:
   . Federal governments participation in the health field.
  . Changing patterns of illness and new modalities of treatment.
  . A new emphasis on the treatment of chronic diseases.
  . Extension of health care benefits to employees through OSHA.
The principal areas in which these changes made their impact on the physical plan of the
hospital were:
  . Size, type and distribution of inpatient care units.
  . Growth of outpatient services and increased emphasis on ambulatory care.
  . Role and design of emergency departments.
  . Inter-relationships of the various departments within a hospital.
  . Overall relation of the hospital to the community it serves.
  . Regionalisation of the health care system.

 Scientific medicine administered through hospitals has proved to be very costly. Publicly funded
insurance and compensation plans and state-funded free medical care have helped to ease this
problem in Europe. In the United States private health insurance has been the favored method. In
the course of the 1970’s, it became clear that private insurance protection against high hospital
costs was inadequate, and the creation of a further national health insurance program has
become a political issue. It is also widely believed, however, that insurance programs have
underwritten the rising costs of hospital medicine while promoting unnecessary use of hospital
facilities. At the same time, rising costs have produced cutbacks in hospital services as well as
hospital closures, raising again the problem of accessibility to care for the poorest groups in
society.

 Today, the weight of economics, social values, and futurist ideas necessitates a reassessment of
this series of these“gifts” of history. Some of these gifts have become liabilities. The reasons for
original design are important; if they are understood, it will be easier to decide whether the
reasons apply today. If not, new designs should be created.