Architecture and Social Distancing: A Long View
We plan to include more features and editorial content on our website. To get us started, our Programmes Officer and Trustee, Dr Ann-Marie Akehurst - an expert in hospital and healthcare design in the early modern period - takes a long view of space and social distancing.
Ann-Marie Akehurst
I am writing this from a Cumbrian cowshed – otherwise known as a ‘shippon’ – at the bottom of our garden: keeping my distance. Social distancing – a concept with which we are all now familiar – refers to actions aimed at limiting the spread of contagious disease by reducing the chance of contact between infected and healthy people, minimizing disease transmission. It’s not a new idea and has been practised in informal and institutional settings for centuries, long before people understood the origins and behaviour of infectious disease. Writing about early modern hospital architecture is complicated: there are dangers of being trapped by Whig historiography that presents the past as part of an inevitable progression towards ever greater liberty and enlightenment. Though Western science and medicine have increased our understanding of, and ability to manage disease, there are no guarantees that they – or culture and politics – will continue on the same trajectory. There are many theories of history, and the notion of ‘progress’ is more up for scrutiny at this moment than any I can recall. Seventeenth-century European debates between the Ancients and Moderns are echoed in current discourses surrounding globalisation and insularity, and embodied traditional knowledge versus empirically generated innovation. That rhyming of history grows increasingly loud, so a history of clinical containment demonstrates that some aspects of what we are being asked to do have very long roots.
Dating back to antiquity, and given a full outing by Galen (129–216 AD), miasma theory posited that diseases arose from contaminated water, spent air and poor hygiene, and were transmitted through ‘miasma’ – a poisonous vapour filled with particles from decomposed matter, identifiable by its foul smell. Persistent adherence to this theory hampered the understanding of diseases until the late-nineteenth-century acceptance of germ theory. From the seventeenth century, designers of large institutions as prisons, barracks, palatial hospitals and alms-houses, were aware that great numbers confined together were prone to typhus, often referred to as ‘gaol fever’. At places like the Wren’s Royal Hospital, Chelsea (1692) or Hawksmoor’s Berwick Barracks (1721), architects designed long ranges with opposing windows and free-standing pavilions as the most efficient way of observing the crucial requirements of disease prevention: separation and segregation.
Escaping urban confinement was also known from antiquity, and people with options practised social distancing independently. Such were the young men and women sheltering in a secluded villa in Fiesole outside Florence to escape the Black Death, who supplied the narrators for Boccaccio’s The Decameron (1353). Villas and country houses were always, in some respects, places of retreat: rural spaces are often protected from densely populated centres of disease. Daniel Defoe’s A Journal of the Plague Year (1722) is a first-person account of one man’s experiences of 1665, when the Great Plague struck London. By contrast, between 1665 and 1667, Isaac Newton decamped to Woolsthorpe Manor, escaping the plague affecting Cambridge. Reflecting this sensibility of rural salubrity, some new English hospitals in the eighteenth century were located on the edges of towns, and many resembled country villas.
At that time, England was woefully under-resourced: its only hospitals were in London and, from 1660, the rising population, increasing urbanization and the risk of disease all created growing demand for hospital beds. When James Gibbs was commissioned to remodel St Bartholomew’s in 1720 – in part a response to panic following the plague epidemic in Marseille from 1719 that killed 100,000 people – complete rebuilding was required. Richard Mead’s Discourse Concerning Pestilential Contagion (1720) inferred from previous epidemics the need for segregation, and demonstrated the usefulness of international knowledge and experience through understanding the functioning of European quarantine hospitals, or lazarettos, derived from lazar, denoting a sufferer from infectious disease, especially leprosy.
Gibbs was also familiar with European models. By regularising Bart’s with four separate pavilions, he improved the functioning and healthiness of the building, permitting air to circulate through and between the structures. [fig. 1] Bart’s became a model for the Royal Naval Hospital, Plymouth, which in turn influenced the nineteenth-century rebuilding of the Parisian Hôtel-Dieu. Gibbs’s pavilions drew on French precedents, and their model increasingly satisfied clinical requirements across the British Empire and North America, and were also adopted in European hospitals. Good ideas – like diseases – are no respecters of political boundaries.
Social distancing was necessary to protect from endemic diseases such as leprosy and smallpox, and diseases imported from foreign goods and contact such as plague and yellow fever. The word ‘isolation’ is derived from the French, isolé, or isolated – placed on an island. The locus classicus of European hospitals is that on Tiber Island, in the middle of the River Tiber, formerly the site of an ancient Temple of Aesculapius, the Greek god of medicine and healing. It was located for its isolation from the rest of Rome, protecting the populus from plague and illnesses. Perennial British exceptionalism was justified in a similar respect: as an archipelago, Britain was conferred some degree of protection. Its separation from Continental Europe (to say nothing of its centuries-long break in provincial hospital foundation) distanced it from the European tradition of constructing lazarettos, especially around the Mediterranean littoral.
Instead, Britain made do with hospital ships that, in theory, should have been extremely salubrious, remote as they were from population and surrounded by moving air. The navy anchored them off naval bases until the construction of hospitals at Haslar and Plymouth in the late eighteenth century. But a ‘tight ship’ also confined much travelled people, who in turn inhaled below decks the output of putrefied animals and sappy air from green ships’ timbers. It was only with the burgeoning British Empire, and the further expansion of the navy, that permanent institutions became important. Britain’s first purpose-built naval infirmary was on the newly acquired colony of Menorca. There, between 1711 and 1715, designers constructed the classically idyllic hospital of its day on an island in the centre of Mahón harbour, optimized for fresh air and light.
A thousand years earlier, in the early eighth century, the Umayyad caliph Al-Walid I built the first hospital in Damascus and ordered the isolation of people infected with leprosy from other patients in the hospital. Historically, leper colonies and lazarettos were established to prevent the spread of contagious diseases through social distancing until transmission began to be understood, and effective treatments invented. Plague- or peste-houses isolated sufferers from the general population, often across water. Southern European plague houses featured a chapel, positioned for optimal visibility, and their form was derived from the Lazaretto of Milan. There, 288 multiple-occupation cells encircled an immense court around a central Tempietto so inhabitants could witness Holy Mass. The pentagonal lazaretto in Ancona (1733–38), for instance, was designed by Luigi Vanvitelli (1700–1773) complete with a central freestanding ‘aediculum’. [fig. 2]
‘Quarantine’ is the compulsory separation, confinement and restriction of the movement of healthy individuals who have potentially been exposed to an agent to prevent further contamination should infection occur. The word comes from the early Venetian quarantena, ‘forty days’, denoting the isolation period for ships before disembarkation during the Black Death pandemic (1348). Famous for international trading, Venice innovatively championed disease control by appointing public-health guardians at the outbreak of the Black Death, and founding in 1403 the first lazaretto on a small island, now called Isola del Lazzaretto Vecchio. [fig. 3] Genoa followed suit in 1467, and in 1476 Marseille’s former leper hospital was converted into a plague hospital.
As European empires expanded, travel for commerce, warfare, or leisure increased risk of contagion. Many ports, where there was risk of importing yellow fever and cholera, established a quarantine hospital. Lazarettos were characterized by the combination of martial and mercantile functionalist building. The Hôpital St-Louis et St-Roch at Rouen (1654) possibly originated the sanitary pavilion-style plan and was probably familiar to Gibbs. There two distinct hospitals flanked a wide court; against the main ranges four blocks formed separate courts, enclosed on three sides. The fortress-like Genoa lazaretto dominated the harbour and conformed to this plan. [fig. 4]
Much of what we know of early lazarettos comes from my personal hero, English social reformer John Howard (c.1726–1790). Howard’s wide-ranging surveys of European practice in the late eighteenth-century illustrated examples in Venice, Marseilles, Genoa, Spezia, Livorno, Messina, and Trieste. Howard designed his own ideal lazaretto, endorsed in Patrick Russell’s Treatise of the Plague (1791), which united clinical and commercial priorities in its recommendations.
Simultaneously, Manuel Pueyo’s Lazareto de Mahón (1785–97) – responding to an epidemic in Algeria – realized an ideal that can still be clearly understood from aerial photographs. [fig 5] Surrounded by water, on an island two hundred kilometres from the mainland, it served Spain’s entire Mediterranean seaboard. On arrival travellers were assessed as either clean, or suspected, or confirmed as harbouring disease. The first categories were quarantined in the two larger zones, behind paired seven-metre-high walls; observation towers ensured quarters remained incommunicado. Goods and travellers alike were fumigated before admission, and goods were ventilated in open-sided stores. Infected patients were isolated in the smaller arrow-shaped zone, adjacent to the cemetery, with supplies but no nursing, where they remained until death. Its colonnaded wards echoed Italian isolation hospitals; patients witnessed Holy Mass though barred cells facing the celebrant in the Tempietto. Mahón combined optimal location and tradition with contemporary understanding regarding patient isolation, fusing ancient and modern. Despite the lack of contemporary understanding of the vectors of contagion, the practices of separation and fumigation were, for a century, very successful in containing endemic plague.
Pavilion-planned general hospitals were built across the world in the nineteenth century. Their effectiveness was gradually supplemented by notions of public health and by germ theory, developed by physicians like John Snow (1813–1858), who investigated the water supply during London’s 1854 cholera epidemic, and Ignaz Semmelweis (1818–1865), who limited puerperal fever by compelling doctors to wash their hands before examining pregnant women. Though such discoveries started to underpin disinfection protocols and pharmaceutical treatment, fever hospitals continued to be established in the countryside, isolating patients with infectious diseases such as diphtheria, typhoid fever, smallpox, and tuberculosis. If you’re looking for infection-related literature that is lighter and less existentially taxing than Albert Camus’ currently popular La Peste (1947), try Betty MacDonald’s The Plague and I (1948), which humorously recounts her eight-months stay in 1937 at Firland TB Sanatorium, Seattle.
So, hospital architecture has long reflected the internationalism of scientific knowledge-production, though Italy’s contribution to disease control has been considerable, and not just architectural. Boccaccio’s Decameron remains, for me, perfect separation literature. To lighten their isolation and pass the evenings, besides participating in chores and prayer, each party member narrates a story, resulting in a hundred tales told across two weeks, exploring themes of fortune, human will, love and virtue. Though perhaps now conducted digitally, this long-standing understanding of the importance of cooperation and retired sociability seems an excellent model for us all as we are hunkered down, separating ourselves from Coronavirus in 2020.
Howard’s Ideal Lazaretto
Fig. 1 St.Bartholomew’s Hospital
Fig. 2 Ancona Lazaretto
Fig. 3 Venice Lazaretto
Fig. 4 Genoa Lazaretto
Fig. 5 Lazareto de Mahon