STUDY AND COMPARISON OF TWENTIETH-CENTURY AND POSTWAR HOSPITAL DESIGN

Study and comparison of twentieth-century and postwar hospital design

Efisio Putzolu

Acknowledgements

I would like to express my sincere gratitude to Dr Tanja Poppelreteur that, even if she was not my supervisor, has always found the time for a meeting in her busy schedule and to my supervisor, Dr Emeka Efe Osaji for his guidance and his suggestions.

I wish to thank my colleagues, who have always been available for me, my family for their continuous and unparalleled love, help and support, and my friends that even when I am not present for them, they are there for me. Particular consideration deserves my friend Andrea, for his help and his sincere advice when I moved to Manchester.

Finally, but most importantly, I thank my partner Nadine for her patience, unconditional love and full support.

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List of figures

1. Aalto, A. (1933) Aerial view of the Paimio Sanatorium. Re-

trieved from http://alvaraaltosarchitecture.blogspot.com/2014/09/ the-paimio-sanatorium.html 2. Le Corbusier (1914). Domino House. Retrieved from https:// www.pigeon-studio.com/maison-domiso 3. Le Corbusier (1933). Le corbusier exercising outdoor. Retrieved from http://www.fontecedro.it/blog/category/le%20corbusier 4. Aalto, A. (1933) Patients sunbathing in the terrace of the Paimio Sanatorium. Retrieved from https://archeyes.com/paimio-sanatorium-alvar-aalto/ 5. Andre, F. (!930) Patients sunbathing in the revolving sanatorium. Aix-Les-Bains. Retrieved from http://thelivinglaboratory. org/2021/1930_dr-saidmans-rotating-solarium/ 6. Andre, F. (1930) Revolving Sanatorium by Andre Farde and Jean Saidman. Retrieved from http://thelivinglaboratory. org/2021/1930_dr-saidmans-rotating-solarium/ 7. Duiker, J. (1915) Laundry facility by Jan Duiker and Bijvoet.

Retrieved from https://ita.archinform.net/arch/308.htm 8. Duiker, J. (1926) Aerial view of the Zonnestraal Sanatorium.

Retrieved from https://en.wikiarquitectura.com/building/zonnestraal-sanatorium/ 9. Duiker, J. (1926) Top plan of the Zonnestraal Sanatorium showing the uninterrupted views. Retrieved from https://docplayer.nl/47032287-Ruimtelijke-verkenning-ensemble-zonnestraal-hilversum.html 10. Duiker, J. (1926) Top plan of the Zonnestraal Sanatorium showing the intersections with the axis of simmetry. Retrieved from https://docplayer.nl/47032287-Ruimtelijke-verkenning-ensemble-zonnestraal-hilversum.html 11. Duiker, J. (1926) Interior view of the cruciform shaped building. Retrieved from https://miesarch.com/work/1254 12. Duiker, J. (1926) Exterior view of the Zonnestraal Sanatorium.

Retrieved from https://miesarch.com/work/1254 13. Aalto, A. (1933) Top plan of the Paimio Sanatorium. Retrieved from https://www.mdpi.com/2076-0752/7/4/78/htm 14. Aalto, A. (1933) Exterior view of the Paimio Sanatorium. Retrieved from https://www.mdpi.com/2076-0752/7/4/78/htm

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15. Aalto, A. (1933) Sketches of patients rooms by Alvar Aalto.

Retrieved from https://www.studiointernational.com/index.php/ aalto-and-america

List of figures

16. Aalto, A. (1933) Picture of a patient room in Paimio Sanatorium. Retrieved from https://divisare.com/projects/386217-alvar-aalto-fabrice-fouillet-paimio-sanatorium 17.Aalto, A. (1933) Exterior view of the angled wing of the Paimio Sanatorium. Retrieved from http://kvadratinterwoven.com/paimio-sanatorium 18. Aalto, A. (1933) Interior of the Paimio Sanatorium. Retrieved from http://www.lozie.com/home/sanatorium-paimio-finland-2/ 19. Aalto, A. (1933) The Paimio Chair. Retrieved from https:// www.scandinaviandesign.com/alvar-aalto-paimio-sanatorium/ 20. Aalto, A. (1933) Architect Aino Aalto sunbathing in the Paimio Sanatorium terrace. Retrieved from https://blogs.getty.edu/ iris/saving-alvar-aaltos-paimio-sanatorium/

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Table of contents

2. Acknowledgements 3-4 List of figures 6 Introduction 7-11 Architecture, health and modernism 12-16 The Zonnestraal Sanatorium 1926 17-23 The Paimio Sanatorium 1933 24- 26 From mid-nineteenth century to postwar

hospital design

26 Conclusion 27-28 Bibliography

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Introduction

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In this paper I analyze the role of the modernism movement in the history of hospital design, mostly focusing on the period comprised between the late nineteenth century and Postwar era. This span of time was affected by different factors, as the deadliest infectious disease seen on Earth, Tuberculosis, and the shock of the World War. Modern architecture was a response to nineteenth century overstuffed Victorian Houses, it cleaned itself from all the unnecessary ornaments fulfilled with dramatic memories for making space to white, smooth surfaces free from what was a surplus in a design now conceived as functional and free from the dust that ornaments accumulated and that was synonym of disease.

Architecture was now based on hygiene and its client was the tuberculosis patient. Doctors and architects started to work close together with the aim of finding a cure through the design. The most advanced technologies in the treatment of tuberculosis were the same newly developed technologies used in Le Corbusier’s design, roof terraces, balconies, and glazed walls above all that gave the access for the only cure available for tuberculosis, a mix of sun, rest, and fresh air. Along with these new principles, a revival of the aspects of Romanticism was becoming influent in all the arts. It was the Biocentrism, which was a more holistic approach to life compared to the rationalistic and machine-driven philosophy of the nineteenth century.

Modern architecture was strongly affected by biocentrism.

This reflected mostly in the design of hospitals and especially tuberculosis sanatoriums. Architects as Jan Duiker in the Zonnestraal Sanatorium and Alvar Aalto in the Paimio Sanatorium showed the new holistic approach of modern architecture based on a close connection between patients and nature, placing their well-being at the center of their design. With the improvement in the comprehension of bacteria through the theory of germ, the discovery of penicillin in 1928 and the consequent widespread of antibiotics in 1940s, psychological and social needs of patients were neglected in hospital design.

In this paper, after having described the relationship between architecture, health and modernism, I will analyze two of the most symbolic building in modern architecture, the aforementioned Zonneestraal Sanatorium and Paimio Sanatorium, and I will then compare the hospital design of the middle nineteenth century with that of modernism and postwar era.

Architecture, health and modernism

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Between the mid-nineteenth and the mid-twentieth century, medical facilities such as asylums and sanatoriums were built. Their purpose was to isolate and treat patients affected by diseases as tuberculosis and lunacy.

Tuberculosis was an infectious disease strongly linked with the new urban working class which lived in overcrowded houses with a big lack of sanitation. Even though there were various attempts by organizations as the Life Reform movement in Germany or the Garden City movement in The United Kingdom at improving health conditions, nothing changed much. As the working class was the most affected group by the disease, consequences on the European economy were inevitable. (Bryder, 1988) In the same period, a new cultural movement called modernism was taking place and its path had to cross inevitable with the problems that tuberculosis brought to light. This intersection played a great role in the establishment of the main principle of modernism, improve health and hygiene for everyone. (Atkinson, 2018) This situation caused major exponents of architecture, medicine and philosophy to join forces in order to fight this disease using design as the weapon. However, this was not the first time that medicine and architecture worked together.

Indeed, architecture and medicine have been connected since the ancient past. Vitruvius during the first century BC insisted that all architects needed to study medicine stating that the sick could have been cured faster through design.

Theories of medicine were integrated into architectural theories, making architecture a sort of branch of medicine.

Design schools from the Renaissance, as “L’ Accademia delle arti del Disegno” in Florence, used dissected body as a central reference for architecture. While doctors studied the human body by dissecting it, architects understood building by drawing sections cuts of them. Even though Modern Architecture is often linked to concepts as modernisation in construction technologies and materials or functionalism, the sick body of a tuberculosis patient is what has driven its concepts. Indeed, if we overlay a map of the distribution of tuberculosis with one of the distributions of modern architecture, they would perfectly match. The engine for modernity was an illness. (Colomina, 2019) The beginning of the twentieth century saw the return of Romanticism ideals together as a holistic attitude towards nature and the experience of the unity of all life. This biologistic Neo-Romanticism, simply called Biozentrik or Biocentrism in German, was a reaction to nineteenth-century obsession with materialism and to its ideal that nature was driven by mechanical principles. The relation between nature and the inner self was fundamental in Biocentrism (Botar, 2011).

Architecture, health and modernism

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Biocentrism holistic ideals reflected also in modern architecture, indeed tuberculosis sanatoriums were physical tributes to nature and its connection with the patient.

This was visible in Alvar Alto’s design of the Paimio Sanatorium which will be analysed later in this paper.

It is crucial to consider also another phenomenon who caused great losses to Europe, the First World War. People were traumatized by this event and architecture had to work on this psychological aspect. Adolf Loos, an Austrian architect, focused his studies on this aspect and his architecture was conceived as a shelter for the nerves of the post-war man. In his book “Ornament and crime” he argued that modern design should have had a sort of anaesthetic effect with its smooth surfaces and that modern man could not tolerate and did not need ornaments anymore, as they would have brought back memories when what they really wanted was a fresh start (Banham, 1960). This theory was followed by other architects of the period, as Frederick John Kiesler who wrote that after the end of the war people changed their habits, they started to get rid of what was a surplus in design and this was just the functionalism happening, a reaction to the overstuffing of the Victorian Age. The removal of ornaments in favour of smooth surfaces and more whiteness became a recognisable mark of modern architecture (Colomina, 2019) In 1882, German microbiologist Robert Koch discovered the tubercle bacillus. However, before this discovery, there was a medical book who attributed the cause of the disease to lack of exercise, sedentary indoor life, defective ventilation, deficiency of light and depressing emotions. Moreover, tuberculosis was thought as a wet disease produced by damp cities, the patient needed an environment to dry the inside of his body. The nineteenth-Century architecture was labelled as unhealthy and sun, light, ventilation, exercises, roof terraces, hygiene and whiteness were now seen as the cure of tuberculosis. As long with these concerns, in the late nineteenth century following raising concerns about fatigue a boost in outdoor exercise happened (Campbell, 2005).

One of the most influent exponents of these concepts was Le Corbusier. He pointed his finger towards the traditional house, cause of debilitating effects of tuberculosis, and towards twentieth-century cities, guilty of being in a state of decline as they were still in the Middle Ages. In his book “Vers un architecture” he wrote, “The machine that we live in is an old coach full of tuberculosis”. Le Corbusier’s idea of the modern house was that of a machine for health that had its own medical devices, pilotis, columns that kept the structure raised from the humid ground where disease breeds, roof gardens, where people could exercise and

1. Aerial view of the Paimio Sanatorium (1933) 2. Dom-Ino house by Le Corbusier.

(1914). This house was a modular structure made of concrete that eliminated load-bearing walls and gave more freedom to the designer. It became crucial in Le Corbusier and modernism architecture.

3. Le Corbusier exercising outdoor.

(1933) Exercise was understood as a therapy against tuberculosis and fatigue and during the start of the tweentieth century there was an enournmous increase in outdoor exercise. It was promoted by influent figures, and Le Corbusier was one of them.

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Architecture, health and modernism

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sunbathe, glass walls, in order to gain as much sunlight as possible in the interior of the house and last fresh air, outdoor air consistently circulating inside the house and ready to be used by lung (Le Corbusier, 1985). These became the main features of modern architecture design and they were used independently in house design and medical facilities as Sanatoriums.

Many modern architects designed a Sanatorium during their career. The sanatorium was seen as a structure where architects, often in collaborations with doctors, could test new materials and techniques. They were usually placed away from the local community, often in forests or mountainsides, in order to create a connection between building, patient and nature but also to try to keep the disease away from the cities. As the protracted exposure to the sun was considered as the best available cure to Tuberculosis, these buildings were designed in order to catch as much light as possible, making them solar devices. The architect Andre Farde took this concept to the extreme by designing a revolving sanatorium in 1930. It was raised sixteen meters from the ground, it was long twenty-five meters and it constantly turned towards the sun. Sanatoriums were a revolution under the social aspect. Until late nineteenth-century, hospitals were medical facilities for the poor, while rich people were treated at home, but with the advent of Sanatoriums and their modern designs, the aristocracy started spending long period of time in these facilities (Colomina, 2019).

In 1910 in Davos, a little town in the Swiss Alps, there were twenty-six sanatoriums, making it the epicentre of the modern cure. One of these sanatoriums was The Schatzalp, the first building to be constructed of concrete and steel in Switzerland and became the model for the modern Sanatorium.

It was claimed to have the most advanced medical treatments available, which coincided with the most advanced technology in modern architecture. It had a hundred meters long façade and huge terraces where patients spent most of their time, even during the winter. (Overy, 2007) The Wald-Sanatorium, situated in Davos as well, housed Katia Mann, wife of Thomas Mann that inspired him to write The Magic Mountain, a novel set in a Swiss Sanatorium.

(Colomina, 2019)

4. Patients sunbathing in the terrace of the Paimio Sanatorium.(1933) 5. Patients sunbathing in the revolving sanatorium. Aix-Les-Bains. 1930.

6. Revolving Sanatorium by Andre Farde and Jean Saidman. Aix-Les-Bains. 1930.

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Case study: The Zonnestraal Sanatorium 1926

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In the late nineteenth century, Netherlands’ architecture was dominated by Hendrik Petrus Berlage, considered the father of modern Dutch Architecture. His theories of architectural function combined with social utility inspired most of the Dutch architects of the 1920s (Blundell, 2005).

Thanks to its neutrality, Holland had the privilege of escaping the physical and social trauma caused by the First World War, hence it became the focal point in the development of Modernist Ideas (Crouch, 1999).

One architect that stood out among the others was Jan Duiker with his designs based on light and fresh air, as expressed in the Zonnestraal Sanatorium.

During 1905, Holland’s Diamond workers Union proposed the creation of a Sanatorium aimed at the cure and rehabilitation of diamond workers affected by tuberculosis.

The air breathed in the polishing workshops was contaminated by dust particles and made easier the development of respiratory conditions, that facilitated the subsequent contraction of tuberculosis (Zoetbrood, 1984).

In 1919, thanks to the money donated for this cause, a property of more than two hundred and seventy acres in the North-West of Hilversum was bought by the union itself.

It was divided into two distinguished natural areas, one was a thick forest and the other comprised fields of heather, that were sunnier and more exposed to fresh air than the forest (Koenders, 2010). The Sanatorium rose in the middle of these two areas.

The realization of the Sanatorium was firstly appointed to Berlage, but he refused as he had already a big contract for another project. Thanks to a convincing proposal inspired

by Frank Lloyd Wright’s work, the project was then assigned to Johannes Duiker and Bernard Bijovet (Milelli, 2000).

The assigned name of the Sanatorium was Zonnestraal, which means ‘Sunbeam’, a clear reference to De Stijl art movement idea of beneficial and therapeutical power of the sun. Before handing over their final proposal, Duiker and Bijvoet took some time to study other Sanatoriums spread across the globe. They came up with more than a single distinctive final proposal and each of them was inspired by a different Sanatorium, for instance, a proposal labelled as ‘First Proposal’ was similar to the North American Tuberculosis Hospital Cook County in Oak Forest while another proposal resembled the King Edward VII Tuberculosis Sanatorium in Sussex, a place that Duiker went to visit together with his wife and a doctor who has following the Zonnestraal project (Zoetbrood, 1984). Due to the 1920 global crisis, the project was temporarily suspended until 1923, when an improvement in the economic condition occurred. In the same year, the

Case study: The Zonnestraal Sanatorium 1926

committee went to the United Kingdom to visit Papworth antituberculosis Colony in Cambridgeshire first and then Royal Victoria Hospital in Edinburgh next. After this trip, Duiker wrote a letter to the members of the commission, in which he highlighted his willing to not build a Sanatorium composed of cottages or pavilions similar the British ones, as the commission was advising to do. While the architects and the commission were trying to reach a compromise, in 1924 they were commissioned for two new projects by the same committee, a laundry facility, to extract diamond dust from workers’ uniforms, and a pavilion house for Jan Van Zutphen’s wife (Molema, 1986).

The laundry was a precursor of some concepts and features that would be later seen in the Sanatorium, where there was a clear search for the ‘spiritual economy’, a way of understanding architecture that goes beyond financial economics but seeks immaterialization and spirituality in architectural constructions (Garcia garcia, 1995).

In 1925 Duiker and Bijvoet took different paths, the first moved his studio in Amsterdam while the second moved to Paris. Between 1925 and 1926 the final project became a reality thanks to the collaboration between Duiker and civil engineer Jan Gerko Wiebenga. Forms and ubication were constrained to the decision of the commission to give up the idea of having a compact Sanatorium, in favour of a scheme more similar to the cottages of Papworth tuberculosis Colony. Duiker was concerned about some aspects, such as the orientation of the building towards the south, the views of the landscape from the building and the dimensions of the front façade. He designed four different plans accordingly to commission requests and trying to find the best solution to his concerns (Zoetbrood, 1984).

7. Laundry facility by Jan Duiker and Bijvoet.

1924-1925.

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Case study: The Zonnestraal Sanatorium 1926

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This approach to architecture was close to M. Ginzburg’s ‘functional method’, in which every architectural problem which rose during the design phase was solved like any other, through the precise clarification of the unknowns. (Garrido, 2007). Duiker found geometry as a useful tool to resolve these problems, a decision influenced by Berlage’s vision of geometry, that according to with Pedro Iglesias Picazo’s book ‘La habitacion del enfermo. Ciencia y arquitectura en los hospitals del Movimento Moderno’ stated in an interview in 1908 ‘Time changes trends (...) but what is found on geometry and science always remains.’ (Picazo, 2011).

Furthermore, the choice of using concrete gave him a high level of freedom for the shapes of the building. Duiker created a symmetric and radial building complex consisting of various centres arranged along the axis of symmetry, the first centre coincides with the north-central structure.

As the site sloped towards the south, this structure was elevated and central, so it gained maximum importance in the complex’s hierarchy. The complex embodied three main separate buildings, linked through glazed corridors.

The upper building includes the administrative block where also operating theatre, X-rays, and an intensive care little ward for six patients were situated, while the lower building was where the main kitchen and the boiler rooms were (H, C. H., 1932). Both these buildings were low-rise in order to leave an uninterrupted view to the central structure and climax of the whole complex, a cruciform shaped building that accommodated a massive recreational and dining area where all the patients gathered. The Greek cross-shaped building summarized the importance of sunlight and fresh air in Duiker’s method. In fact, it was glazed from floor to ceiling in each side and it also presented large roof lights to gain even more sunlight. The level of transparency of the building transformed the interior spaces in an extension of the exterior, to create a close link with the surrounding nature, also claimed to be beneficial for the patients as much as the sunlight. (Overy, 2007) This concept was remarkable in Frank Lloyd Wright’s architecture and his book published in 1954 The Natural House in which he wrote “I began to understand dwelling not as a cave, but as a spacious outdoor shelter, connected with the inside and outside views” (Wright, 1954). Following his geometric method, the architect distributed the accommodations in different blocks, paired in groups of two and shifted about forty-five degrees one from the other in order to offer interrupted views to the south-facing rooms. In addition to the outstanding views, this disposition boosted exposure to sunlight and fresh air for patients. The angles were not left empty, indeed there were common rooms that caught an abundant

8. Aerial view of the Zonnestraal Sanatorium.(1926) 9. Top plan of the Zonnestraal Sanatorium showing the uninterrupted views.(1926)

10. Top plan of the Zonnestraal Sanatorium showing the intersections with the axis of simmetry.(1926)

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11. Interior view of the cruciform shaped building.(1926)

Case study: The Zonnestraal Sanatorium 1926

amount of sunlight too. There were a hundred accommodations designed for single occupancy, divided into two wings of twenty-four, with twelve accommodations per floor, and two wings of twenty-six, with thirteen accommodations per floor and every single one of them had direct access to the outside thanks to the circulation that was placed in their north side (H, C. H., 1932). Even though patients were alone in the room, they still had the possibility of interacting with people on the same floor and share all aspects of this confined experience. They were all men, and they had airy workshops of wood to keep them actively employed and prepare them to their return to work. Both the interior and exterior of the building were completely white, to transmit an idea of hygiene and to reflect even more light in the interior. (Molema, 1986) The Zonnestraal Sanatorium was inaugurated on the 12th of June 1928 and it remained in use until the Streptomycin was discovered, making it obsolete and leaving it to dereliction. Only after several decades, this masterpiece of concrete and glass has been restored to his original form and nowadays it is serving as a multi-purpose health facility.

(Ishida, 2017)

12. Exterior view of the Zonnestraal Sanatorium.

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Case study: The Paimio Sanatorium 1933

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Finland was part of the Kingdom of Sweden for centuries but in 1809 it became part of the Russian empire as an autonomous Grand Duchy. A great sense of nationalism raised among the Finnish population during the 19th Century. Finnish Architecture until this period was dominated by architects from the Swedish-speaking part of the country ,where the prestigious schools were, while Finnish architects had to go abroad to receive their education (Quantrill, 1983). This proceeded until the 1890s when the Finnish National Romantic movement took the stage. The pioneers of this movement were the painter Akseli Gallen-Kallela and the architect Lars Sonck, who was the winner of 1894 architectural competition for the Church of Saint Michael in Turku. With his designs, Sonck set the principles of Finnish architecture. The beginning of the 20th century saw an incrrease in Finnish architecture’ s confident, as demonstrated by the fact that Finland started producing its own architectural critical journal, Arkitekten. Following the rise of the architectural journal, architects were starting to look beyond the imposition of the Russian empire and Finnish architecture was now being recognised globally through the National Romanticism. At the beginning of 1920s, young Finnish architects labelled National Romanticism as regressive and they became influenced by Neo-classicism. However, by the end of this century, thanks also to the independence from the Russian Empire gained in 1917, Modernism and Functionalism became the biggest influences in Finnish Architecture. (Miller,1982) In 1898, in Kuortane, a small town in Finland, something that will change the future considerations of Finnish architecture happened. Indeed, during this year one of the most influent Finnish architect and designer was born, Hugo Alvar Henrik Aalto. He dominated Finnish architecture for almost half a century and had the merit to make Finland visible and highlighted in the Architecture map. (Quantrill, 1983). As mentioned earlier, Finnish people developed a strong sense of nationalism and attachment to their folklore, which could be a cause of mind closure towards the rest of the world. In Alto’s case, it could have limited his horizons in architectural studies and research but, being raised in a westward – looking environment of a Swedish speaking family helped him avoiding this risk. His background gave him the possibility of having his own personal view of Finnish architecture in the much broader European architectural context, and international influences helped him understanding and admiring more Finnish traditions and creating an indestructible bond between him and the National Romantic movement (Quantrill, 1983).

Case study: The Paimio Sanatorium 1933

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Indeed, in Aalto’s early work is clear his attempt to extend symbolic design attitude from the National Romantic movement and Neo-Classicism in his individual interpretation of modern architecture. His ability to modify and mix these traditions with international influences is what makes Aalto’s work unique. His designs presented familiar elements in both original and new forms and this was how he anticipated modern reactions to functionalism. His first work as functionalist happened in October 1927, in his three designs for the Viipuri Library competition. His designs looked over the ninetieth century Greek model of neoclassicism developed by German architects, implementing a new humanistic approach in which people’s needs and people’s interactions with his architecture were the focal points of the project. This was a completely new approach, an evolution from the rationalistic architecture of his contemporaries(Curtis, 1996). Aalto expressed architecture as a living organism that must be experienced and enjoyed and not just a box for accommodating functions. He made this concept visible in his design of the Paimio tuberculosis Sanatorium in 1929-1933. (Colomina, 2019) Even though this building stands in Aalto’s modernist period and was designed accordingly to Le Corbusier’s pioneering ideas for modernism, like roof terraces and ribbon windows, it also shows a preview of Aalto’s later move to a more synthetic approach. (Aalto, Reed, 2002) The Sanatorium is a seven storeys building, remotely situated about 29km from Turku in a thick pine forest that offered outstanding panoramic views for the patients. It is informally planned, the wings radiate from the centre at different angles, based on the direction of sunlight and views. (Richards, 1978) The complex comprised three main wings, in wing “A” patients’ rooms and rest halls were situated, a corridor linked this area to wing “B”, where communal areas, treatment, and therapy rooms were placed, while wing “C” consisted of technical and service rooms.

(Fleig, 1990) The outstanding feature of the building was its asymmetrical sun terrace system cantilevering from a single concrete reinforced spine column. This system offered a large sun terrace in each storey of the east wing of the building, which was slightly angled in order to face south and gain as much sunlight as possible. This because the only available treatment for tuberculosis at the period was long exposition to the sun and fresh air. The schedule of accommodation of the building comprised meeting rooms, public spaces, staff housing, a double-height cafeteria and walking path through the surrounding forest for encouraging self-sufficient patients to go for walks (Fleig, 1990).

13. Top plan of the Paimio Sanatorium.(1933)

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14. Exterior view of the Paimio Sanatorium.(1933)

Case study: The Paimio Sanatorium 1933

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The purpose of these walks was to connect patients with the surrounding nature causing a consequent feeling of relaxation in them, as well as improving their physical condition.

The patients’ rooms received particular attention, but before explaining them, a little introduction must be made.

When Aalto took the planning, he was ill himself and he had the chance to experience the disease on his skin and to understand the human aspects involved. He understood that rooms were designed for people who spend their day in a vertical position and not for those who have to spend their days in bed. In particular, he noticed that his eyes were constantly irritated by the electrics light. The recovery from tuberculosis was very long, and not successful in many cases. Spending all this time confined in the bed of a Sanatorium room can be tremendously depressing for the patient and, to worsen the situation, the conventional hospital was not designed in order to accommodate the needs of a person constantly laying horizontally. Aalto’s view of the sanatorium experience was different, he recognised the needs of the patients as what should have driven his design and his architecture had to be connected with sorrounding nature and work as a medical instrument instead of being architecture in service of medicine (Colomina,2019).

In his design for patients’ bedrooms stood out his accurate search for a harmonious connection between service and quiet zones, a sort of complete peace. One of his first decision was to design two-beds bedrooms instead of the more used three-beds rooms, which could have provided more flexibility in the accommodation of the patients but less privacy and quietness. (Fleig, 1990) As mentioned earlier, Aalto understood by his personal experience that light fixtures could not remain in the ceiling, as they would strain patients eyes all day and indeed light sources were moved away from patients’ field of view. The ceiling suddenly became a crucial component of a patient’s daily life, it became a sort of new façade. The colour of the ceiling had to be dark and indeed blue was chosen, as it stimulates quietness and relaxes, and the walls were in lighter shades. All the patient’s rooms were oriented towards the forest and the view from the window had to be calculated taking in considerations the point of view of the reclining patient. (Fleig, 1990) Even in the terrace, the low parapet allowed for a breath-taking view for a horizontal person. Elevators were placed at the end of the corridor, so they would not be a source of disturbing noise for patients in the rooms, and they were encased in glass in order to provide a horizontal view of the landscape beyond sanatorium’s walls for

15. Sketches of patients rooms by Alvar Aalto.(1933)

16. Picture of a patient room in Paimio Sanatorium.

(1933)

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Case study: The Paimio Sanatorium 1933

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travelling patients moving in bed or in wheels (Colomina, 2019). The heating was directed to patient’s feet, and not their head as usual, and windows were constructed in a way that allowed cold from outside to enter only diagonally (Fleig, 1990) Mechanical ventilation was present only in the main kitchen because, as Aalto said during a lecture in Italy describing Paimio, ‘natural ventilation with fresh, ozone-rich air is of the utmost importance in the healing process’. (Schildt, 1995). Patients bedrooms did not have any ornaments, because they could have caused accumulation of dust and, for the same reason, the intersection between wall and floor was curved in the proximity of the windows. (Mccarter,2014) Last, but not least, was the top terrace located seven stories above the pine forest, where patients were brought to take their daily doses of sun and fresh air. Sadly, due to the numerous suicides, it had to be closed off. (Colomina,2019) Aalto’s holistic approach is not confined to the patient experience of the building, but it expands also to that of workers. Indeed, the colours of the different areas of the building were not casual, as for example the reception space, the staircase and the corridors presented a Bright Canary Yellow who evoked happiness even in the cloudy days and all the rooms have been meticulously placed to offer different views and shade of lights to all users.

(Mccarter, 2014). Aino Alto, Alto’s wife, and Alto himself designed furniture and sanitary fittings of the bedroom, as sinks that avoided splashing and chairs designed in order to facilitate breathing, as the iconic Paimio Chair which was the physical representation of Aalto’s humanistic approach to design. This chair, firstly seen as a specialized piece of furniture then became everybody’s chair and today it is still in production. (Colomina,2019) Nowadays the Paimio Sanatorium does not work as a tuberculosis sanatorium anymore, but its healing environment is still in use as a health facility (Woodman, 2016).

17. Exterior view of the angles wing of the Paimio Sanatorium.(1933)

19. The Paimio Chair. (1933)

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18. Interior of the Paimio Sanatorium.

(1933)

20. Architect Aino Aalto sunbathing in the Paimio Sanatorium terrace.(1933)

From mid-nineteenth century to postwar hospital design

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In the second part of the nineteenth century, a British nurse called Florence Nightingale had a great role in the development and establishment of a new model of hospital design, the pavilion ward system. The pavilion ward design was a consequence of the British colonization.

Indeed, setting up a successful medical facility would have increased rates of success in the colonization, but Britain was having difficulties under this point of view. For example in Crimea, where the mortal rate of the newly established British military hospital from disease and secondary infectious was as high as that from battle wounds. Volunteer nurses were sent to Crimea to improve the medical conditions of the hospital, and among them, there was Florence Nightingale. In a brief period, mortality rates dropped down drastically, and the nurses were recognised as the authors of this improvement. Nightingale gave the majority of the credit to a substantial improvement in hygienic conditions in the wards and she defined hospital disease as preventable through the use of accurate building hygiene (Kisacky, 2017). Her book “Notes on Hospital” became a point of reference for the late nineteenth century and early twentieth-century hospital design. She defined the ideal hospital as a structure formed by different and independent pavilions, each one designed as a large and narrow ward with some service spaces and windows on all walls. Nightingale saw the circulation of fresh air through the wards and the availability of clean water for patients as essential in a medical facility. Additionally, she was concerned about the psychological aspect of being in a hospital, especially in the connections between patients and nature, which became a key concept in later Sanatorium design. As she wrote in her diary “I mention from experience, as quite perceptible in promoting recovery, the being able to see out of a window, instead of looking against a dead wall; the bright colour of flowers, the being able to read in bed by the light of a window close to the bed-head. It is generally said that the effect is upon the mind. Perhaps so, but it is not less so upon the body on that account. …” ( De Swaan, 2006).

During the early twentieth century, modern architects conceived their architecture as a sort of medical instrument. They amplified Nightingale’s ideas of fresh air and nature through designs driven by biocentric ideals in which the inner self and nature were central, and the resulted building was thought as the therapy for the disease. As described by Jeanne Kisacky in her book “Rise of the Modern Hospital”, they were “Full of sunshine, fresh air, and labour-saving technologies, the new architecture would create a new, modern, politically liberated

From mid-nineteenth century to postwar hospital design

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society, full of healthy citizens” (Kisacky, 2017). The aforementioned Zonnestraal and Paiomio Sanatoriums have been two masterpieces of modern architecture, designed as machines for healing in response to the tuberculosis pandemic. The construction of the Zonnestraal Sanatorium started in 1925, and it influenced the design of Paimio Sanatorium which opened later in 1933. Indeed, Alvar Aalto visited the Zonnestraal Sanatorium in 1928.

These two Sanatoriums had the most advanced medical technology, which corresponded with the most advanced technologies in architecture, south-facing , glazed walls, balconies, and terraces above all. In the Zonnestraal Sanatorium, enormous importance was given to the experience of the patients during his staying and this concept was even more visible in the Paimio Sanatorium, where Alto created a healing environment addressing each patient’s psychological and social needs.

In 1928, Alexander Fleming discovered penicillin. This discovery led to the widespread use of antibiotics by the 1940s. Antibiotics were an effective treatment, even though infections continued to occur patients did not die from them anymore. The problem of nosocomial infections, the modern equivalent of hospital disease, was solved and as result, the link between the hygienic conditions of a patient’s surrounding and infections rates seemed irrelevant. There was not the need of bringing the healthy exterior environment into the interior anymore (Kisacky, 2017). The hospital design was now driven by efficiency and technological determinants while psychological and social needs of patients were neglected.

In post-war hospital facilities designers recreated optimal interior conditions artificially, orientation and dimension of windows did not matter anymore as artificial light overwhelmed sunshine in the same way as air conditioner replaced fresh air. Indeed, hospitals were moved from the rural to the urban areas and, although natural ventilation was crucial in modern architecture, increasing concerns about the actual cleanness of urban outside air compared to filtered conditioned indoor air made the last become the most adopted air circulation system in hospitals (Guenther, 2013). An extreme example of this was Neergaard’s controversial “double pavilion plan” presented in 1942, in which criticisms were centred on the dark, windowless patient rooms placed in the middle of the pavilion. Neergaard was seeking for the most compact and efficient scheme for a hospital, as every architect was doing in the 1940s (Kisacky, 2017). The old one-story pavilion-ward hospital necessitated long travel distances and the architect had to find a more flexible solution where

From mid-nineteenth century to postwar hospital design

Conclusion

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travel distances were reduced, so less staff was needed, and less money was spent. This resulted in optimized deep floor plans and vertical plans, that became possible thanks to the advent of improved vertical transportation systems. The outcome was an urban block-plan hospital without courtyards or green spaces as the building made impossible the creation of a direct connection with the ground plane for large numbers of patients. (Guenther, 2013). Nature was taken out from the equation and hospitals were now industrial and sterile spaces.

The uplifting concern on patient’s mental well-being developed in the first part of the twentieth century was suddenly made irrelevant by the advent of antibiotics. The holistic ideas of Alto and duiker were replaced by a constant search for efficiency and flexibility, leaving the social needs of a patient in a windowless dark room placed in the middle of a pavilion of an urban Hospital. Nature was eradicated from the hospital environment that had preferred decontaminating ultraviolet lights and mechanical ventilation to sunshine and fresh air.

A study conducted in 2018 by professor Veronica Soebarto and Doctor Mohamed S. Abdelaal criticizes design strategies of twentieth one century sustainable hospitals which are mostly focused on their impact on the environment and it proposes the development of a true sustainable hospital, described as “a restorative environment that connects human health with nature by combining salutogenic and biophilic design principles with restorative environmental design strategies”. (Abdelaal, 2018) In the twenty-one century, the biocentric ideas applied in the design of Sanatoriums at the beginning of the twentieth century are more modern than ever.

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