Architecture of Isolation
Harriet Richardson (Edinburgh University)
The conversion of the ExCel Centre in London into NHS Nightingale – the mega temporary hospital capable of being extended to provide 4,000 beds – mimics earlier measures to cope with hospitals overwhelmed by cases of infectious disease. Though nothing on quite that scale, as far as I am aware. The last pandemic that occurred in Britain, the ‘flu that ran rife after the First World War, completely overwhelmed the systems in place to deal with infectious diseases which included a nationwide network of isolation hospitals. These hospitals had been built in response to a series of earlier epidemics, which had given rise to a sequence of public health acts, variously aimed at improving environmental health, preventing the spread of disease, and containment when disease did occur.
As the onus on action was placed at local level, and legislation advised on measures that could be taken, rather than dictating what must be done, responses to epidemics varied across the country and often took too long to be truly effective. With inadequate existing hospital accommodation, outbreaks of smallpox and cholera saw houses, factories and barracks commandeered. In Aberdeen a disused match factory was turned into a temporary hospital by the City Corporation after an outbreak of smallpox in the early 1870s. In most cases once the outbreak subsided the temporary hospitals closed and any plans to build permanent isolation hospitals were abandoned. But at Aberdeen a permanent hospital was begun in 1874, designed by the City Architect, William Smith II, and unusually constructed of concrete. This was chosen on the principle that the wards could be hosed down and disinfected after use. Even the floors were of concrete. Later, timber floors and panelling were inserted to soften the rather prison-like interiors. (Ills View of one of the ward blocks at the City Hospital, as altered and enlarged to designs by John Rust in the 1890s https://canmore.org.uk/file/image/1374923 and Detail of a plan of the City of Aberdeen from the Post Office Directory of 1879, showing the ‘Epidemic Hospital’ on the outskirts of the city. Reproduced by permission of the National Library of Scotland)
Detail of a plan of the City of Aberdeen from the Post Office Directory of 1879
Until about the 1860s there was no consensus regarding ideal hospital design. Of the few purpose-built fever hospitals erected in the 18th and early 19th centuries, some had small wards arranged on either side of a corridor with the idea that smaller groups of patients limited the risk of cross-infection, others large open wards with twenty or more beds. The presence of such a hospital – often optimistically dubbed a ‘house of recovery’ – on one’s doorstep was understandably unpopular. When one was set up in a house off Gray’s Inn Lane the neighbours threatened legal action to have it closed. It decamped northwards, and eventually became the London Fever Hospital, designed by Charles Fowler and built in 1848-9 on Liverpool Road, Islington. Here a mix of small, large and back-to-back wards seems evidence of a lack of confidence in any one system. (Ill coloured engraving of the main front of the London Fever Hospital. Reproduced from the Wellcome Collection https://wellcomecollection.org/works/pspzgh6a and plan from The Builder, 12 August 1848, p.391)
General hospitals also took in infectious cases, sometimes against their own regulations, but needs must. The London Hospital and University College Hospital both set aside wards for contagious cases in the 1830s and 40s. Other hospitals built separate fever blocks, one of the largest was at the Royal Infirmary in Glasgow, built in 1828-9 (Ill The west front of the Fever block, probably photographed around 1910. From the Wellcome Collection CC-BY-4.0). The Poor Law Amendment Act of 1834 (and its counterparts in Ireland of 1838 and Scotland of 1845) not only saw a network of workhouse built across Britain but also of associated infirmaries and fever blocks. A small single-storey fever hospital was built as early as 1836 at Stow-on-the Wold workhouse in Gloucestershire.
Legislation continued to encourage the provision of isolation hospitals, but hospitals were expensive to build, and raising the money from local rates to pay for them as unpopular. In the midst of each succeeding epidemic local authorities accepted that available hospitals accommodation was disastrously inadequate, but had seldom gone farther than proposing to take action before the epidemic subsided and the initiative was lost.
In London the Metropolitan Poor Law Amendment Act of 1867 resulted, eventually, in a comprehensive network of fever hospitals around London, linked by an efficient horse-ambulance service. Public fear remained strong. The building of a large smallpox hospital in Hampstead was considerably delayed by local opposition. Most isolation hospitals were built well away from the denser urban areas, and floating hospitals served by river ambulance operated from wharves at Fulham, Blackwall and Rotherhithe. (Ill Aerial photograph of the Brook Fever Hospital, Shooter’s Hill, London built by the Metropolitan Asylums Board and opened in 1896. Wellcome Collection. Attribution 4.0 International (CC BY 4.0)
Outside London, from the 1870s the construction of isolation hospitals was overseen by the Local Government Board, and following the 1875 Public Health Act loans were made available to build them. Low cost solutions widely adopted were the purchase of a tent that could be put up and used in emergencies, or the erection of temporary, pre-fabricated hospitals. Hospital huts of timber and corrugated iron were supplied by various companies: Humphreys of Knightsbridge; Boulton and Paul of Norwich; Speirs and Company of Glasgow being three of the largest and most enduring. The corrugated iron block near Hempsted, to the south-west of Gloucester, may have been supplied by Humphreys – Gloucester was listed as one of the places supplied by the firm. A smallpox epidemic in 1874-5 had raised talk of erecting a temporary iron hospital. An even worse epidemic struck the city in 1895-6. Dr Sidney Coupland prepared a lengthy report, attempting to assess why this epidemic had been so much worse than the previous one, and to what extent re-vaccination had contributed to its rather abrupt cessation. Some of his observations strike a chord today: ‘It is possible that the hope was entertained that by an attempt to isolate every case as it arose the epidemic might be checked, but this attempt only resulted in filling the hospital beyond its capacity and over-burdening a too-restricted staff.’ (Ill. This Hempsted Smallpox Hospital, Gloucester, photographed by H.C.F. in 1896 Wellcome Collection. Attribution 4.0 International (CC BY 4.0))
Where permanent buildings were erected, they were usually based on standard plans drawn up by the Local Government Board and issued between 1876 and 1924 in a series of memoranda. The model plans adopted the pavilion principles of planning, validated by Florence Nightingale, with open wards, windows placed opposite each other to create cross-ventilation, and W.C.s placed away from the ward, separated from it by a cross-ventilated lobby at the very least. These were intentionally draughty places. Currents of air were drawn through the wards through open windows, ventilation grilles and ducts. Drainage too, became increasingly important to keep infected waste out of the water supply. The new isolation hospital for Hemel Hempstead, built in 1914-15 at Bennet’s End, is a typical example. It was designed by John Saxon Snell and Stanley M. Spoor and comprised two single-storey ward blocks, an observation block, a service building housing the laundry, with steam disinfector, mortuary, and ambulance garage, and an administration block with nurses’ accommodation. The wards were intended for the most prevalent diseases at that time, diphtheria and scarlet fever, with the observation block for the undiagnosed. (Ill A ward block built at the Hemel Hempstead Infectious Diseases Hospital at Bennet’s End, based on the model plans issued by the Local Government Board. LGB model plan B, 1900 and 1902-21 versions. The Bennet’s End ward has elements of both. Ward block photographed in May 1992 as part of the RCHME Hospitals survey: LGB model plans from Local Government Board On the Provision of Isolation Hospital Accommodation by Local Authorities August 1900, and reissued in 1902.)
Progress in medical knowledge was reflected in hospital design. A better understanding of the transmission of diseases and the discovery of bacteria were factors behind the development of the cubicle isolation block. This first appeared in the early twentieth century. One was built at Walthamstow which consisted of rows of single rooms reached from an external veranda. This allowed patients suffering from different diseases, or who were yet to be diagnosed, to occupy one building. Glazed partitions between the rooms allowed nursing staff to supervise the patients, as well as allowing patients to see each other. By about 1940 almost every isolation hospital in the country had at least one cubicle block. At Twickenham the former South West Middlesex Hospital was originally built in 1898 to designs by W. J. Ancell comprising four ward blocks and the usual service buildings. Two cubicle isolation blocks were added in 1937 as part of a major extension of the hospital. Following the Local Government Act of 1929, provision for infectious diseases passed from the myriad of small local urban and rural sanitary authorities to county and borough councils, this also led to many of the smaller hospitals being replaced by larger more centralised hospitals. (Ill Cubicle isolation block built at the South West Middlesex Hospital, exterior and interior views. Photographed in November 1991)
Wide-ranging public health measures to improve living conditions were the first effective weapons in lessening the impact of infectious diseases. Improved housing, sanitation, and street cleaning, regulation of lodging houses and factories, testing for food adulteration, were all vital preventive measures. Local Medical officers of health had a wide network of resources from laboratory research to morbidity and mortality statistics, to help them control epidemics through isolation, supervision of carriers and contacts, tracing the source of infection and the pathways by which it spread, and interrupting these by whatever means were available. Vaccines, inoculations, and effective treatments, for the most part, came after the Second World War. Since then we have been in a period of epidemiological transition, shifting from an age of receding pandemics and into an age of degenerative and so-called man-made diseases (those associated with lifestyle, such as heart disease, or lung cancer from smoking).
Infectious diseases were not wiped out, but could be treated within a general hospital. Post-war general hospital design included a higher proportion of single rooms in ward units to allow patients to be isolated for a variety of reasons, cross-infection being one of them. An experimental ward unit built at Hairmyres Hospital, East Kilbride, in the 1960s, was used to study ways of reducing cross-infection, but one of its findings was that human error remained a major culprit. Medical, nursing and domestic procedures could be one source, but also misuse of the engineering services. They found ventilation diffusors and exhaust grilles blocked up by the medical staff.
Photographs of the interior of NHS Nightingale show the huge open warehouse being fitted up with cubicles – here to facilitate laying on all the necessary services for each patient rather than isolating one from another. A dedicated hospital for infectious diseases is an old solution, but it is still a valid one, provided the infrastructure, the equipment and staffing are also in place – along with the necessary training in how to operate the appliances and services.
View of one of the ward blocks at the City Hospital
Coloured engraving of the main front of the London Fever Hospital
Plan of the London Fever Hospital from The Builder, 12 August 1848, p.391)
Aerial photograph of the Brook Fever Hospital, Shooter’s Hill, London
This Hempsted Smallpox Hospital, Gloucester, photographed by H.C.F. in 1896
A ward block built at the Hemel Hempstead Infectious Diseases Hospital at Bennet’s End, based on the model plans issued by the Local Government Board
LGB model plan B, 1900 and 1902-21 versions
Cubicle isolation block built at the South West Middlesex Hospital, Exterior
Cubicle isolation block built at the South West Middlesex Hospital, Interior