Architecture as Machines for Healing

A reading of ‘Sickness, Madness and Crime as the Grounds of Form’

建築是治療的機器 — 讀《疾病、瘋狂、犯罪作為形式基礎》

Tao Zhu 朱濤

The essay ‘Sickness, Madness and Crime as the Grounds of Form,’ written by architectural historian Robin Middleton, offers a detailed account of the design experiments in hospitals, asylums and prisons in Europe of the 18th and 19th centuries. Amid the current Covid-19 pandemic, this article extracts historical narratives of hospital design in Middleton’s essay and his detailed examination of how architects and medical practitioners attempted to create hospitals as ‘Machines for Healing.’ These designs were manifestation of their creators’ negotiations between providing more empathy and care for patients and the urge to shape hospitals into more robust surveillance and disciplinary facilities. Middleton begins his essay by referencing Michel Foucault’s Madness and Civilisation, noting how the ‘Great Confinement,’ lasting from mid-17th century to the end of 18th century, was identified by Foucault as a period in European history where undesirable elements of the society, such as the sick, insane, beggars and criminals were forcibly removed and kept behind walls.

In Paris alone, 6,000 persons, or about 1% of its population, were locked away in the ‘hôpital générals’ established in each principal French town. While discriminatory attitudes towards these ‘wild and degraded elements of society’ improved after the 18th century, efforts were, however, not geared towards integrating them into the society, but rather to exploit them for labour, using architecture as a tool to reform deviant behaviour through work rehabilitation. The relationship between architecture and biopolitics became more explicit after the fire in Hôtel-Dieu of Paris on 29 December 1772. Established in the 8th century, this oldest hospital in Paris was first built on the parvise of Notre-Dame and began to expand towards the south side of the Île de la Cité, a river island on the Seine, before sprawling across both riverbanks. The 1772 fire decimated wards located on the island but also provided the ideal opportunity to modernise the hospital. From 1772-88, more than 200 suggestions and 50 schemes were proposed for the new facility, many of which incorporated medical theories of the day. Since it was popularly believed then that poor ventilation caused disease transmission, physician Jean-Baptiste Leroy envisioned a large hospital compound on the right bank of the Seine with separate ward buildings for female and male patients set symmetrically about a court dominated at one end by a chapel. This design, touting its ability to promote good ventilation, became known as the pavilion-type plan.

A small committee of physicians and scientists was convened by the Académie des sciences (French Academy of Sciences) to test the viability of Leroy’s claim. They chose four sites in Paris, each suitable for constructing a hospital of approximately 1,200 beds. Four designs based on the pavilion-type were commissioned and all proved the viability of implementing Leroy’s design. This moment was exalted as the ‘absolute solution to the problem of hospital design.’ Such unwarranted optimism, however, unsettled Jacques Tenon, a chief surgeon at Hôpital Salpêtrière and a medical instructor at École de Chirurgie (School of Surgery). Since different diseases exhibited differing symptoms, Tenon rationalised that the choice of hospital site and design must therefore correspond to and be customised according to the specific requirements of the patients and their treatments. Using La Roquette, one of the four sites selected by Académie des sciences as an example, Tenon modified the pavilion-type plan with wards served by a central corridor rather than a court. The arrangement and number of beds in every ward and the size and distance between beds were also carefully calibrated, not to prevent contagion, but to restrict and control the movement of delirious patients. This physician-led revolution in hospital design seemingly defined the needs of the sick and devised spatial programme to fulfil them with precision and economy. Even though architects were largely sidelined during this process, exceptions such as J.-N.-L. Durand, a 19th century architecture professor at the École Polytechnique, well known for his architectural publication, Recueil et parallèle des édifices de tout genre, anciens et modernes (Collection and comparison of buildings of all kinds, old and modern) were further involved in developing and reconciling cutting-edge medical theories with the aesthetic considerations of 19th century neoclassicism. The integration of science, arts and technological advancements in French hospitals, in the forms of hot water heating and ducts for artificial ventilation, became increasingly elaborate, before reaching its zenith during the redevelopment of Hôtel-Dieu’s from 1864-77.

Despite the efforts invested in 19th century hospital design, including the unusually long period of reconstructing Hôtel-Dieu, the effectiveness of such pavilion-type hospitals was often in doubt since the new design did not prove to be more effective than conventional hospitals in reducing the death toll. It was only until 1867 when British doctor Joseph Lister advanced the germ theory as a cause of infection that people began to understand how diseases were primarily transmitted through microscopic vectors. With that came the realisation that architecture had all along, been inadequate in preventing the spread of contagion.

(English summary by Ian Tan 陳昱宏)
年初我在香港居家隔離期間,選擇在第一周細讀羅賓•米德爾頓(Robin Middleton)的長文《疾病、瘋狂、犯罪作為形式基礎》(以下簡稱為“《疾瘋犯》”。這篇五萬字長文含巨量的「實證」史料,結構也很特別:第一部分綜述十八、十九世紀歐洲(焦點是法英兩國)對醫院、瘋人院和監獄的設計探索; 第二部分聚焦講兩位元法國建築師 Emile Gilbert(1793-1874)和Abel Blouet(1795-1853),如何在法國將歐洲三類建築的實驗推向高峰,修建了馬紮斯監獄(Prison de Maza)、夏朗通瘋人院(Asile de Charenton)和巴黎新主宮醫院(Hôtel-Dieu de Paris)。 篇幅所限,本文僅抽取關於醫院設計的論述。


在十五世紀到十七世紀初的歐洲文化中,「瘋癲」曾是歐洲人日常經驗的一部分。但從十七世紀中期到十八世紀末——福柯稱為「大禁閉」時代,收容機構的規模和權力大增,將各式各樣「非理性」 、「不待見」的人都關起來了,包括瘋子、病人、罪犯、乞丐等等。在1660年前後,巴黎關押了超過6,000人,佔1%的城市人口。這些人被不加區分地鎖在一起,被極粗暴地對待。

到十八世紀末,人們的態度又開始變了。一方面,在文化表現上,戈雅的繪畫和薩德(Marquis de Sade)的文學著力探索那些長期被理性忽略和壓迫的原始、野蠻、瘋狂的力量,而這些力量以後將傳遞給尼采、Antonin Artaud(法國劇作家),直到達達主義和超現實主義者。另一方面,也可從很實際的角度理解人們對「問題人群」的態度轉變:當權者意識到關押成本太高,而被關押者(如投入勞動)實際上有經濟潛能。當然,當權者的各種實際考量也往往建構到更高尚的話語上——人道關懷。總之,十八世紀末歐洲開始出現針對「大禁閉」的改良思想:「窮人要被鼓勵去工作,病人和瘋子要被治癒後也去工作,犯人則同樣也要被救贖。」

「改良的工具居然是建築……」 米德爾頓寫道:「當時人們想,建築如果能被精准地設計,幾乎不需其它幫助,就能影響結果。」

醫院建築:科學 vs 藝術
引發對建築進行全新探索和評估的契機是巴黎主宮醫院的一場大火。主宮醫院是巴黎最古老的醫院。它的建築自八世紀起,在巴黎聖母院旁邊持續擴建,一直蔓延到西岱島(Île de la Cité)南邊和塞納河兩岸。1772年的一場大火將醫院在西岱島上的大部分病房毀掉。(fig 1)

 針對主宮醫院的重建,在1772-1788年間,共有200多個建議、50多個建築方案被提出來。有建築師開始提出「醫療服務網路」的設想。比如Pierre Panserson提議在巴黎分散佈置16個小醫院,同時在天鵝島(Île aux Cygnes)上建設一座五千床大醫院。Panserson的大型設計方案提出一種新穎的佈置方式,秩序感很強,但並沒有對疾病治療做深入探討。

 還有些方案試圖根據醫學理論推導出醫院新形式。在當時,醫學界普遍認為空氣不流通是疾病傳染的主要原因,因此通風成了一些建築師的首要設計考量。Antoine Petit提議在美麗城 (Belleville) 建設一個巨型醫院,平面像個大風車。圓環中心是風塔,吸入新鮮空氣,向周邊放射狀的病房(風道)吹。(fig 2) Hugues Maret則將病房的牆壁和天花都設計成「流綫型」,以加強空氣流動。

而醫生Jean-Baptiste Leroy設想的建築群位於塞納河右岸、天鵝島對面,呈雙邊對稱,中間設一個巨大庭院,盡端設一個教堂。男女病房對稱分佈在兩邊,各有十一排,平行行列式,之間隔有小庭院——這種平面佈置後來被稱為「亭子類型平面」。在病房層高很高。每個病床靠兩邊牆壁,有小隔間分隔。地板架起,表面設有圓洞,屋頂天花呈拱廊狀,上面也有風洞,便於通風。

 法國科學院為推動醫院設計研究,專門組織了一組科學家成立了一個委員會。該委員會決定自己動手,在巴黎選四個場地,以Leroy的亭子類型平面為基礎,設計出四個方案,每個規模在1200床位左右。最終他們的設計結果,實際上都很接近Leroy的構思。 委員會原本目標是要開發出一個完美模式。而恰恰是這種要找到一個絕對答案,可解決一籃子設計問題的思維方式,卻遭到了委員會成員、外科醫生Tenon的抨擊。Tenon認為探索醫院設計不可能一蹴而就。他的邏輯前提是針對不同疾病,醫院的選址和設計都應不同。比如在同一醫院中,不同種類的病人要分開,配以各種特定設備。

Tenon選了其中一個場地拉羅屈埃特(La Roquette)做示範,設計一所可容納472個男性和310個女性受傷或發燒病人、422個產科病人的醫院。Tenon也採用了亭子類型平面,但他用一條中央服務通廊而不是庭院來串聯各翼病房。只能裝一個病人;病床要用鑄鐵做,可以用水洗或火燒,以驅趕蝨子;病床尺寸和間距嚴格按人體行為推算;每間病房內不超過24個床位,以便於監護;在天花病房中,病床每兩個一組,設在一個小隔間裡——不是為了杜絕傳染,而是為了防止病人在精神昏亂中不至於蹣跚得太遠,打擾別人;病房中不同部位的窗戶尺寸和形狀,以及天花高度都按照不同疾病的需求,經過計算決定,等等。總之,Tenon的設計將從Leroy到科學院委員會的一系列關於醫院如何完善治療功能的探索,推向了極致。


建築界也試圖做些回應。法國建築學會聽取了科學院的報告,舉辦了醫院設計競賽。巴黎布紮學院的教授J.-N.-L Durand還將Leroy 和Tenon設計的平面圖刊登在他1800年的《古代與現代所有種類的建築類型選集和目錄》 (Recueil et parallèle des édifices de tout genre anciens et modernes)中。 但兩年後,Durand在他的經典教程《建築課程簡記》(Precis des lecons d’architecture)中講述醫院設計原理時,僅介紹了泛泛原則。他所重繪的平面圖中,空間佈局都變得更加對稱,病房尺寸和組合都變得一樣,庭院都被封閉起來。科學院和Tenon所強調的那些治療空間的精微差別、複雜性全都消失了。Durand讓他所弘揚的「藝術」,再次淩駕於科學之上。

而此後,Tenon的觀點被不斷提及,他的亭子平面佈局自1808年起在一批法國醫院設計中成為通用模式。醫院建築外殼圍裹的內部是日趨複雜的服務系統——各式各樣的機械通風、蒸汽和熱水採暖的管井和綫纜。最終,在1864-77年Emile Gilbert主持的巴黎新主宮醫院設計中,所有這些元素都更加精密、複雜和整合,將醫院設計推向高峰 。


直到1867年,英國醫生Joseph Lister推出細菌理論,人們才懂得了細菌傳播的原理和管道。到那時,醫療在預防傳染和隔離手段上變得更加周到,而不再僅僅依靠建築設計了。

這時,實證主義思想體系已經開始出現裂痕,人們對建築的期待值也開始降低。從此,哲學和科學,醫學和心理學開始從不同角度衝擊建築學,形成不同結果。比如, 「新心理學」(Psychologie Novelle)與新藝術運動 (Art Noveau) 的互動就是其中一個有趣例子。


一大批文學家和藝術家,從於斯曼 (J. K. Huysmans) 、普魯斯特、馬若雷勒(Jacques Majorelle)、羅丹到加萊 (Émile Gallé) ,都紛紛對臨床診斷非常著迷。玻璃器皿藝術家加萊甚至將自己的藝術定義為「脈動神經的內在世界向外的展現」。

人們可以迅速看出,這些藝術作品與十九至二十世紀之交Hector Guimard 和Victor Horta的作品——新藝術運動建築設計有明顯的聯繫。


Tao Zhu is Founding Principal of Zhu Tao Architecture Studio. He is also an Associate Professor and Co-Director of the Centre for Chinese Architecture and Urbanism at The University of Hong Kong.

Fig.1 《巴黎主宮醫院的大火》,休伯特•羅伯特 (The Fire of Hôtel-Dieu in Paris, Hubert Robert, 1772)Nationalmuseum Sweden, via Wikipedia Commons

Fig.2 美麗城上的設計方案 Hôtel Dieu at Belleville by Antoine Petit in 1774 (Source: Université de Paris Library ).

Fig.3 「亭子類型平面」設計方案, Pavilion-type plan, Jean-Baptiste Leroy, 1781(Cornell University Library Digital Collections)

Fig.4 巴黎新主宮鳥瞰圖 Hôtel-Dieu from Notre-Dame de Paris (Credit: Joseph Hunkins from Talent, USA, CC by 2.0)

Fig.5  塔塞爾公寓,比利時布魯塞爾. Hôtel Tassel, Victor Horta, 1895 (via Henry Townsend)