Books
Annmarie Adams the hugely influential The American Hospital
Medicine by Design: The Architect
and the Modern Hospital, 1893–1943
Minneapolis: University of Minnesota Press,
2008, 240 pp., 90 b/w illus. $27.50, ISBN
9780816651146
Annmarie Adams’s Medicine by Design
wears its learning lightly. But readers
should not be fooled. This is an erudite
volume, remarkable for the depth of its
research and the thoughtfulness of its
argument. Medicine by Design tells the
story of a handful of hospitals (and addi-
tions to hospitals) in order to refute the
oversimplified notion that innovation in
medical practice drove architectural
change. Adams’s starting position is that
this was a reciprocal and iterative process
wherein architects influenced doctors and
vice versa.
The full title, Medicine by Design: The
Architect and the Modern Hospital, 1893–
1943, suggests a much larger topic than the
one covered; indeed, Adams’s book is far
from comprehensive, but, except in the
title, she makes no claims to that effect. In
fact, the book places one hospital at its cen-
ter, the Royal Victoria Hospital in Mon-
treal, and one architectural firm, Stevens
and Lee, dominates the study. Nonetheless,
Adams seems oddly ambivalent toward the
man she establishes as the key figure in
early twentieth-century hospital architec-
ture, Edward Fletcher Stevens. She takes
pains not to give Stevens too much credit,
in spite of the fact that he was the author of
Journal of the Society of Architectural Historians 69, no. 1
(March 2010), 115–131. ISSN 0037-9808, electronic ISSN
2150-5926. © 2010 by the Society of Architectural Histori-
ans. All rights reserved. Please direct all requests for
permission to photocopy or reproduce article content
through the University of California Press’s Rights and
Permissions website, http://www.ucpressjournals.com/
reprintInfo.asp. DOI: 10.1525/jsah.2010.69.1.115.  servative and historicizing, but the interiors
JSAH6901_08.indd 115
were technologically modern. Doctors’
in the Twentieth Century (1918, revised in
1921 and 1928), in addition to forty-eight
other articles cited in her bibliography.
This reluctance might have been an out-
come of Adams’s decision to place other
historical actors (nurses, patients, and doc-
tors) in the foreground of her study.
The first chapter, “1893,” offers a
detailed description of the original build-
ing at the so-called Royal Vic, designed by
Henry Saxon Snell, a typical pavilion-plan
hospital. Chapter two considers the expe-
rience of paying patients, outpatients,
children, and pregnant women as they
traveled through the spaces of a few hos-
pitals, with social class and gender inflect-
ing nearly every move. In chapter three,
“Nurses,” Adams notes that the nurses’
dormitory, which had features of tradi-
tional upper-class manor houses, became
a requirement of the early twentieth-cen-
tury modern hospital in order to recruit
middle-class women to the demanding
profession (81). In fact, the architects of
the nurses’ residence at the Royal Vic gave
it similarities to the suburban Montreal
mansions for which they were well-known.
Chapter four, “Architects and Doctors,” is
a profound rethinking of the nature of
expertise, both medical and architectural.
As the non-parallel chapter titles indicate,
the book’s thematic outline is somewhat
willful, and readers must be persistent. But
persistence pays off. While the book can-
not be used as a quick reference, it is chal-
lenging and enriching, and less predictable
than a chronological study would be.
For general readers, chapter five, “Mod-
ernisms,” may be the most engaging. Here,
as elsewhere, Adams’s scholarly contribu-
tion goes far beyond the hospital building
type. The exteriors of hospitals were con-
longstanding obsession with ventilation and
fire prevention placed hospital designers at
the forefront of technical practices. It is not
surprising, then, that the clean lines and
unornamented interiors of, say, a surgical
theater demonstrate medical modernity and
appear to architectural historians as man-
ifestations of the modernist paradigm
in architectural style. As Adams explains:
“Architects evoked historical styles and used
traditional materials for the conservative
outside of their buildings, while finding
multiple and often ingenious ways to incor-
porate and display technologically advanced
medical, service, and managerial equipment
inside” (109–10). In another sense, Stevens’s
Scottish baronial exteriors were also mod-
ern: they were designed to satisfy the
patient’s psychological needs, and Stevens
invoked psychology as a modern field of
medical practice. The author gives nuance
to the concepts of modernity and modern-
ism, inflecting them with disciplinary con-
cerns as well as local historical contexts; the
terms are never taken for granted or used as
empty stylistic descriptors.
Medicine by Design ventures into the
interpretation of material culture and
ephemera as well as architecture. For exam-
ple, we learn about the controversy over
maternity hospitals through an analysis of
vintage photographs of wards and waiting
rooms. Some doctors pathologized child-
birth, while others understood birth as
natural event. The architect Stevens, who
belonged to the latter group, attempted to
create a homelike environment at the Royal
Victoria Montreal Maternity Hospital by
providing lounges with fine wood paneling,
fireplaces, oil paintings, and old-fashioned
furniture (49).
Many architectural historians have
struggled with the gap between the
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 intended use of a building and the way it is
eventually or actually used. We seldom
have post-occupancy evaluations (or the
equivalent) for buildings we care about. In
this regard, the chapters “Patients” and
“Nurses” are the most original, because
they follow the daily pattern of life inside
the hospital after its completion. Here we
learn that well-heeled sick people—pro-
vided with hotel-like entrances and lob-
bies and private rooms—inhabited the
Royal Vic in fundamentally different ways
from poorer patients, who entered the
hospital at a lower level, near the streetcar
drop-off, and shared rooms.
Readers might wish for more compari-
sons to other building types, with college
dormitories, prisons, and psychiatric hos-
pitals coming immediately to mind. Civic
presence, social control, surveillance, ven-
tilation, and fireproofing persist in con-
necting these building types in the minds
of some observers. One interesting line of
argument, perhaps for some other scholar
to explore, is the different historical trajec-
tories of these massive public institutions.
To take one example: just when lunatic
asylums were losing their credibility as
therapeutic places and sites for the pro-
duction of new knowledge, general hospi-
tals were growing in scientific prestige and
architectural extravagance.
Medicine by Design should be com-
mended for many reasons, but the foremost
is that this book breaks methodological
barriers at every turn. The author deliber-
ately ignores the border between the
United States and Canada (xxi); she lev-
els differences between types of histori-
cal evidence (finding profitable insights
in sources from architects’ drawings to
magazine advertisements for rubber
flooring and micro-leveling elevators);
she diminishes the distinction between
the history of architecture and the his-
tory of medicine; and she almost com-
pletely demolishes the demarcation
between vernacular studies and tradi-
tional high-art architectural history. For
Adams, the production of architecture is
a process of negotiation among groups of
people who have vested interests and
often conflicting goals.
carla yanni
Rutgers, The State University of New Jersey

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