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The Architecture of the Hospital: A Study of Spatial Organization and Medical KnowledgeAuthor(s): Lindsay PriorSource: The British Journal of Sociology, Vol. 39, No. 1 (Mar., 1988), pp. 86-113Published by: Wiley on behalf of The London School of Economics and Political ScienceStable URL: http://www.jstor.org/stable/590995.

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LindsayPrior

The architecturef the hospital:a studyof spatialorganizationandmedicalknowledgeABSTRACTThe paper opens with a review of recent developments n thesociologyof spatial organizationand after an examinationof theontologicaland epistemological ssumptionswhichare embeddedwithin currenttheorizationsof space a numberof argumentsareadvanced concerningthe inter-relationshipswhich hold betweenforms of knowledge,social practiceand physicaldesign. Usingarchitecturalplans, these argumentsare then developed withreferenceo the studyof the spatialorganization f hospitalwardsin three contexts; the care and treatment of children, thecontainmentof madness n the pre-1845 periodand the manage-ment of psychiatricpatients1973-1982.The paper concludes hatschemes of spatialorganizationare best understoodn relationtothe discursivepractices ofwhichthey form a part ratherthan asdecontextualisedand reified social facts which exhibittheir own'logic'.

I SOCIOLOGIES OF SPACEThe studyof the social organization f spacehasfiguredprominentlyin muchtwentiethcenturysocialscience iterature, ndthe sociologi-cal account opened by Durkheimand Mauss in 1903 has beenmeticulouslyaugmented hroughouthe twentiethcenturyby a widerangeof work frombothEuropeanand NorthAmerican cholars.Infact, and in marsyways, it is an accountwhichhas given rise to anentire sub-disciplinewithin the wider compassof sociologyitself;namely that of urban sociology.The emphasisupon urbanismhas,however,meant that the overwhelmingbulk of the work has beenwrittenwithin the framework f moderngeography,ratherthan of,say, Durkheimiansociology. Consequently,the primary focus ofattentionhas been on the spatialrelationshipswhichexist betweenb.uildings,ettlements,and holdingsandthe like uponlandscapesTheBritishJournalof Sociology Volume XXIX Number

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The rchitecturefthehospital 87in the widestsenseof that term.Indeed,evenwithinthe mostrecentwritingson spatial structures,such as those of Gregoryand Urry(1985), (whichclaimto radicallyreconstitutehesociologyof space),and Smith (1984), geographyremains indelibly imprinteduponsociology'smanifesto.Yet there s a case to be madefor a sociologyofspacerather hana sociological eographyandthatcase hasalsobeenrecentlyrepresented; specially n the workof such writersas King(1980), Hillierand Hanson (1984) and, to a lesserextent,Giddens(1984, 1985). In this newly conceivedsociologyof space it is theinternalstructureof buildingsas muchas thesettlementof landscapewhichprovidethe fociof attention,and it is inter-mural atherthanextra-muralurfaceswhichconstitutethe planeson whichsociologyinscribes ts analysis.It is just sucha sociologyof spacewhichI wishto followthrough n thispaper,and I wish to do so by concentratinguponthe architecture f the hospital.Hospital architecture s, of course,capableof many and variedforms of expression, and so in order to underline the severalargumentswhichare contained n this paperI intendto concentrateon a fewspecificexamplesof architectural esignas it appears n thehospitalward.My firstexampleswillbe drawn rompaediatricwardsand my later examples from what might be called 'asylum'architecture.The latterexamplesare especially nterestingbecause,unlikethechildren'swards,theyaredrawn roma rangeof hospitalswhichin differentages havebeenknownby a varietyof names,andthe revisions of nomenclatureare undoubtedly correlatedwithrevisionsof design. Indeed, it could be arguedthat theirchangingarchitecturalormshelpin manywaystodefinetheobjectsof therapywhichwere,or are, to be foundwithin theirwalls and it is a pointwhichI hopeto elaborateuponin mydiscussionof twospecific tagesof sucharchitecture iz theAsylumduring he 1807-1845periodandthe PsychiatricUnit 1973-1982. But beforeI actually turn to anexaminationof such architectureI would like to outline somesociologicalprincipleswhich can be appliedto the study of spatialstructures.Withoutdoubt,someof the most fascinatingdevelopmentsn thesociology fspaceemanatedromworkcarried utbytheDurkheimiansduringthefirstfewdecadesof thepresentcentury,and it is thatworkwhich offers the most fruitfulstarting point for any sociologicalconsideration f spatialrelationships.Durkheimand Mauss (1963),for example, in a sociologizedversionof Kantianismargued thatspace and time were ultimatelyformsof social categorizationand,more mportantly,hatsuchcategorizationsxpressed,underdifferentaspects the very societies within which they were elaborated'(1963:66).Classificatorychemeswerethereforemodelleduponformsof socialorganization ndhumancognitiveprocesseswereassumed ohavea socialbase(Durkheim1915).Thegeniusofthe Durkheimians,


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88 Lindsay riortherefore,was to suggestthat spacewas sociallyproduced ather hannaturallygiven and it was on the basis of this suggestion hat almostall furtheradvances n the subjectwere made.As novel as the Durkheimianswere in this field, they nevertheless,(thoughnot surprisingly), ound themselvesunable to cast aside theNewtonian concept of absolute space within which they operated.Both Durkheimand his nephew still regardedspace as a thing initself;as a receptacle or materialor social objects;as one of the twofundamentalcategories n which reality is co-ordinated.For them,space was an arena in which objectswere socially arrangedand re-arranged. And despite the fact that they emphasized the role ofcollectivehuman ife in structuring he processesof arrangement ndre-arrangementheir deference o the Newtonianworldview made itimpossible or them to escape from the space/societydichotomy.The developmentof these Durkheimianprinciples n the work ofthe semioticians also exhibits the continuing influence of basicNewtoniancategorieson sociologicalanalysis. In their world spatialdivisionsand arrangements re viewedas an arena orthe interplay fsymbols.These symbolsand their deeperstructuresare regardedasphenomenawhich need to be decoded n the light of specificculturalcomplexes. Thus Rapoport's work on interiors takes this form(Rapoport1980), and so too does Bourdieu's 1973) famousanalysisof the Berber house. Indeed the latter rests his analysis upon theprinciple hat the house formspart of a symbolic ystem; the house sorganizedaccording o a set of homologous ppositions' 1973: 102)This focusof the semioticians n the interplay f signifier nd signifiedin many ways echoes their broadervision of the relationshipbetweenspace and society. Here is society, expressed in and through therichnessof symbolic ormsand there s space. The firstcontainedandthe second containing; the first is foreground and the secondbackground. t is a Newtonianvision in another orm.Yet, as Gregoryand Urry (1985) argue,space is not simplyan arena n whichsymbolsunfold, but is itself an integral componentof social life. A similarargument romwidely differentpremises s advancedby Hillier andHanson in the early pages of their 1984 work. Thus they argue thatspace, 'constitutes(not merely represents)a form of order in itself'(1984:9).This notion of space as an active ingredient n, ratherthanjust apassivereflector f, social life is undoubtedly f recentorigin.Yet it isa line of thoughtwell worthfollowing. n fact, GofEman1959, 196 1 ,(a sociologistwhose name is rarelyconnectedwith spatial analysis),had alreadyrecognized he ways in whichhumanactorsutilized pacein everydayprojects hroughhis studies of total institutionsand thepresentation f self in everyday ife. In both studieshe entertaininglydescribedthe numerousways in which space could be utilized as aresourceby interactingparties.It was an insightwhichcouldnot have


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The rchitecturefthehospital 89been grasped in the Durkheimiancorpus but which neverthelessprovidesuswithonemeansof linkinghumanconsciousnesscollectiveorotherwise) o physicalartefacts. ndeed,Goffmanwasarguing hatsociologycouldand shouldstudynot merelyhow spacestands 'outthere',externaland opposedto individuals,but howit is usedin thehere and now, in the episodic ventures of social interaction.UnfortunatelyGoffman'sanalysisof space is predictedupon an allconsuminghumanism n which spatialarrangements re given lifeonly in andthrough heprojectsofinteracting gents.It is, however,aperspectivewhichhasbeenapplied o features f hospitalarchitecturewith some success as, for example, in Rosengrenand DeVault's(1963)studyof time and spacein an obstetricalhospital.The fusionof timeand spacealso appears n otherwritingson thephysicalsettingsof human nteractiveprocesses.LikeGoffman's,t isworkbuilt on a visionof spaceas a resource eadyandwaitingto bemobilizedby conscioushumanagents. In fact, the consideration fspace as a materialresourcefor interactingpartieshas been mostrecentlyrevivedby Giddens(1984, 1985)who has combined t withsome of the more basic notions of Hagerstrandso as to analysemovementof the body within time-spacecontexts.Giddensarguesthat, within sociologyat least, space is more often treatedas anenvironmentn whichsocialconduct s enacted, hanas a resource obe mobilized n interactionand he paysparticularattentionto whathe refers o as theregionalizationf socialpractices.The emphasisontime-geography,however,has its originspecifically n the work ofHagerstrand see Gregoryand Urry 1985),in so faras he has givenespecial emphasis to the fact that movement in space is alsomovement n time. Consequently,any analysisof humanactorsandinteractionn spaceis inextricablyinked o ananalysisof theways inwhichactorsand interactionare dispersed hrough ime. Spaceandtime, (viathe intermediary f motion),arethereforedifferent idesofthe samecoinand, withinthisperspective,areregardedn muchthesameway as elementsexternalto the socialworld.Thus, humanaction s seen to unfoldwithinsetspatiotemporalo-ordinates ndthefocus of sociologicalattention is on the ways in which these co-ordinatesare 'used'in everyday ife.As well as an awarenessof absolute space, some writershavedisplayeda keen interest n the organizedproperties f relativespace.Thatis, spaceas it manifeststselfintherelationships etweenobjectsor matter.Hillierand Hanson's(1984)work s a goodexampleof this.Their emphasison the boundarymaintainingcapacitiesof spatialdivisions ogetherwiththeiranalysisof thespatial depth'ofbuildingshas also enabled them to cut free of the kind of Goffmanesquehumanism o whichI previously eferred.Theirformal echniques orthe analysisof spatial relationshipsenablesthem to examinebothlandscapesand buildingswithout referenceto human purposeor


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9oLindsayrior

designndthe 'logic'of buildings s supposedlyaidbarethrough heusef lementaryquantitative echniques.Their workalso has theadvantagef emphasizingthe fact that space is not merelya

receptacleor the containmentof humansociety, but a dimensionwhichonstructsandconstrains hatsociety.In thatsensespaceis aDurkheimianactpar excellence. Indeed,in trueDurkheimianashion,Hilliernd Hansonbelieve n theexistenceof'spatiallawswhicharequitendependent f [human]agency'(1984:36). Nevertheless,heirworks stillwoveninto thatspace/societydichotomyof whichI havespokenndtheydiffer romothertheoristsonlyin so faras theyarguethatpace s a determinantather handeterminedactorofsocial ife.Outof this manifold egacyof spatialanalysisI wish to highlightandeveloponly a fewof the simplerpoints.First,the Durkheimianthesishatspace s a socialproduct eemsto metobeincontrovertible.Itsa themewhich,onceannounced,radicallyredirectsolae'svisionandomprehensionf theworldandit is a thesisthe utilityof whichhaseen recognizedby historiansof the physical sciences.ThusJammer1969)writesThe structureof the space of physicsis not in the last analysis,anythinggivenin natureor

independent f humanthought.It is afunctionof ourconceptual cheme.(1969:173)Inhe social sciences,however,this fundamentalnotion has beendevelopedlmostentirely n relationto landscapes,and thenalmostsolelyy Marxisttheoreticians. In fact,Smith(1984)rather alselyattributeshe thesis of the social productionof space entirely toMarxistiscourse).Second,andrelatedly, heargumenthatspaceisan xternalprojectionof humanconsciousness; representation fmind,s alsoworthyofpreservationn a modifiedorm.For, nso farasspatial ivisionsarehumancreations heymustrepresent

omeorderof onsciousness ndpurposefulnteraction. t is, however,possible oadopt farmoreradicalstanceon thisquestionthanDurkheimandMausscouldpossiblyhave imagined,thoughin orderto do so it isnecessaryo dispensewiththe NewtonianconceptswithinwhichtheDurkheimiansperated.Third, it is necessary o realizethat morethanmererepresentations involved n theorganization f spaceandthatspace is morethan a mereenvironmentn whichconsciousnessandactionunfold.Spaceconstitutesas well as represents ocialandcultural exi3tence; space enters into the very

production andreproductionf human ifeandany analysisof institutional rchitec-turehas to indicatethewaysin whichthisis so. In fact,andin ordertoexplore histhemefurtherwe haveto movesomewaytodissolvingthe space/societydichotomywhichunderpinsnearlyall of the workswhichI haveso farmentioned. n otherwords,we haveto recognizethatspaceis neithera containern whichsocial ifeoccurs,nora merereflectingglassof socialpracticesand socialcategories,norindeeda


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The rchitecturef thehospital 91determinant f socialorder.Rather ike language t has elementsof allof these, but ultimately its significancecan only be fully compre-hended in the context of situatedsocial practices.II DISCOURSE AND ARCHITECTUREIn his Histo?:yf BuildingTypes evsner(1976)accountsforprevailingarchitecturaltyles in terms of the creativityof individualarchitects.Buildingsare interpreted olely as the productof personalimagin-ation. It is a familiarmodeof analysis,but it is one which s somewhatrestricted n explanatory apacity or t entirely idesteps heinfluenceof social life on aspects of physicaldesign. Indeed, it drawsa linebetween social life and design in such a way that buildings areenvisioned as artifacts'out there', apart and divorced fromsocialworlds in which they were conceived.Fortunately, here is, as we know,an alternativemodeof analysiswhich lays stress upon the role of collective human culturein theproductionand reproduction f physicalartefactsand whichlocatesindividualexpressionn a muchwider matrixof forcesthan Pevsnerwould have recognized.But rather than resurrecta crude form ofDurkheimianismhere I intend instead to directly borrow a fewthemes from a morerecent Gallictheoreticianand argue that aboveall a buildingexpressesa discourse,and that architecturalorm canprovideus with a registerof a discourse. n fact,not only canwe readoffdiscursivethemes fromarchitectural lansbut we can also followchanges in discursiveregimes throughthe transformation f suchplans. As a discoursealters, then so too does its visible elements.The term discourse has become somethingof a shibboleth incontemporaryociologicalwritings hough t is important o recognizethat this single term embodiesmany diverse concepts. In Anglo-Saxon sociology,forexample, the concept of discourse s more oftenthan not utilized within a realistontology and, more particularly, tusuallyrefers o a set of linguisticactivities.Thus,discourses alwaysdiscourseabout some thing. Out there is a universeof objectsandherebeforeus is a discourseon that universe.Discourse eportson theworld and the task of sociology s often seen as an unravelling f suchreports, or 'accounts'as they are sometimes referredto (see, forexample,Mulkay (1985)). Discourseanalysis s therebyextendedtocovereitherspeech or texts but doesn'tpay too much attention o theways in which such speechor texts construct hevery objects o whichthey supposedlyrefer.'Intransitiveobjects', as Bhaskar(1975) callsthem, exist independentlyof discourse. In some recent strands ofdiscourseanalysis,however, his realistepistemologys rejected romthe outsetand consequentlyhe notionof discourses endowedwith avery differentset of meanings. Thus, in the work of Foucault,for


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92 ljindsay riorexample,the divisionbetweenthe word and the world s dissolved nthe murkydepthsof idealistphilosophy forhim, the orderof thingscannotbe representedndependentlyn the orderof words.Indeed, tis in this latter context that the term discourse s utilized here.In an articleon politicsand the studyof discourse, whichpre-datesTheArchaeologyf Knowledge),oucault(1978) arguesthat a discourseis constituted through its rules of formation, its conditions ofemergenceand its correlationwith other practices.And he furtherdiscusses he ways in which his own workcentresupon examining hetransformationso whichsuch discursive ormations re subject;upondetectingchanges which affectthe objects,concepts,and theoreticalstructuresof a discourse;upon the analysis of the mutations andredistributions resent n discursive egimesand upon the analysisofchanges and transformationsn modes of practiceembodiedwithindiscursive tructure. ndeed, for Foucaulta discourse s embodiedasmuch in practiceas in theory,and the lattershould n no way be seenas being epiphenomenal o the former.Discursive ormations here-fore necessarilyunfold in specific technicaland materialsettingsParis Medicine in the hospital, madness in the asylum and the lawcourts, natural science within the laboratory,and so on. And theanalysis of such discourses cannot therefore be restricted to theanalysisof spokenor written anguagealone,fora discursive egime sspreadacross many different ypes of statement,only some of whichare linguistic. In this sense aspects of physicaldesign are as solid aformof discursive nunciation s are texts or speech.In fact, buildingstranspose hemselvesas statementsS nd architecturalormsnot onlyofferthe materialsettings within which discursive ormationsunfoldbut also act so as to constitutethe objects to which the discourse saddressed.It is in fact possible to be rathermore specificabout the natureofbuildings within discursive contexts than these broad statementssuggest. Hillier and Hanson, for example, (drawing on modernDurkheimianprinciples), correctly emphasize ( 1984: 146) that abuilding s a domain of knowledge n so far as it embodiesa spatialorderingof categoriesand a domainof control n so far as it involvesan ordering of boundaries. And these expressions of knowledge(especiallyclassificatory ategories),and controlare evidentand canbe read from all architecturalplans (see, for example, Armstrong1985). In Foucaultian anguage,buildingsare mechanisms n whichdifferent ormsof power-knowledgemasquerade nd one task whichconfrontsa sociology of space is to disassemble he componentsofwhatever technology s concealed within given architectural orms.But this is not to argue hat spatialarrangements re meresignifiers fsome other order of reality. On the contrary, patial organization sintrinsicto the very presenceof a discourse.Space does not exist aseither a pre-givenartefact,nor as an afterthought nd reflectionof


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Thearchitecturef thehospital 93human deliberationsbut is integralto, and created n the maelstromof social action. Space and society are not, therefore, wo separaterealmsof realitybut are intertwined n a single orderof existence.Consequently,a sociologyof space has to demonstratehow spatialarrangementsand re-arrangementso-varywith other featuresofsocial life in such a way as to construct,sustainand, occasionally,transformheobjectsof humanpractice.In otherwords,spaceis partof a 'field'and not a backgroundagainstwhichmovement n othersocialactivitiescan be measured.Take for example, Bourdieu's Kabyle house. Its rectangularstructurewith one frontand one rear entrance s combinedwith anabsenceof solid internalpartitions. n a physicalsense,it is a simplebox. Site it next to an example of modern western domesticarchitecture.Amongother things,the latterwillbe seento expressaninfinite control of bodily function and activity the bed-room(furthersub-divided by kinship categories), the bath-room,thelavatory, heliving-room,he lounge,etc. andto embodya culturalcode concerning he distributionand regulationof humanactivitiesand social relationshipsn a mannerquite distinctfromthat of theBerberhouse.And theseprinciplesof westerndomesticarchitectureare in factreflected n a widerangeof architecturalorms, ncluding,as I shallshow,thatof the 'asylum',(in thatsenseit is a shamethatthereare no plans of Berberasylumsto set beside the BethlemsofwesternEurope).These featuresof domesticarchitectureare not,however,meresignifiersof other factsbut are themselves lementsofa widerdiscourseon bodilydiscipline.Neither hesub-divisions f thehouse nor the sub-divisionsof the body and its activitiescan becomprehendedn the absenceof the otherfor, together, hey formafield n whicha wholesetof socialpractices suchas privacy,personalhygiene,social manners,family ife, etc.), are produced.In a similarvein it can be demonstrated hat hospitalplans areessentiallyarchaeologicalrecordswhich encapsulateand imprisonwithin themselvesa geneaologyof medicalknowledge.The studyofalterations n elementsof hospitaland ward design can thus revealchanging objects of medical attention, or disclose innumerableprinciples oncerningheconceptualizationfdiseaseand illness.Theconstruction f children'swards,for example,correlatewith the riseof the childas a focusof medicalpractice;hebirthof theasylumwiththe inventionof madness;and the emergenceof the Pavilionhospitalwiththediffusionofmiasmic heoriesofdisease.Furthermore,pecificelementsof wardand hospitaldesignare capableof revealingsomefine detail concerning he manner n which child illnesses,insanity,surgery, or whatever are theorized in different decades of thenineteenthand twentiethcenturies.And thus the architecturalplanlays bare the spatial expressions n which medicalknowledgeandtherapeuticpracticesare constituted.


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94Landsayrior

Thisapacityof spaceto revealthe numerous tratain whichthe

fossilizedrinciplesof humanaction are embeddedhas, of course,

beenoted y other(andnotablyMarxist)writers.In fact,Lefebvre

hasrequentlyiscussedthe mannerin which landscapesdiscloseprinciplesf politicalactionand arguesthat spaceexpresses,above

all,oliticalnd ideologicalrelationshipsIfpaceas an airof neutralityandindifference

withregard o itscontentsnd thus seems to be 'purely'formal,

the epitomeofrationalbstraction,t is preciselybecause t has

alreadybeenthefocusf past processeswhosetracesarenot always

evidenton the

landscape.pace hasbeen shaped and mouldedfromhistorical

andaturalelements,butthishasbeena politicalprocess.Space s

politicalnd ideological. It is a product literallyfilled with

ideology.Lefebvre,H. 1976:31).Butdeologydoesnt merelysaturate andscapes. t

is ubiquitousnbuildingss well.

III.HE DESIGN OF THE GHILDRENS WAI{D

Awards essentiallya point for the intersectionof socio-medicalpractices.n the discourseof observationalmedicinet is aboveall a

pointor the intersectionof pedagogical, nursingand medical

practicesn which the bed plays the most prominentrole. In these

respectshe children'swarddisplayslittle differenceromits adult

counterpartnd it would seem that from 1852(when the first

children'sardin an Englishhospitalwasopened)untiltheyearsof

theresentcentury, he children'swarddid notrequirea specialized

architecture.n fact, and accordingto the authors of the 1963

Nuflieldtudy on children in hospital, the dominant modeof

architecturalesignwas (forbothchildrenandadults)encompassed

withinhe Pavilionplan.ThedesignofthePavilionhospitalwas,ofcourse,closelyconnected

withhe expressionof a specifictheoryof disease- the miasmic

theoryof disease. Within the terms of this theorythe essential

elementsf a hospitalarchitecture reto be foundn suchfeaturesas

the pacesbetweenpatients, heflowofairthroughhewardsandthe

patternsfventilationbetweenwards.Bothwardsandhospitalswere

designed o as to facil-itatehe dissipationof miasmaandone of the

greatestadvocatesof such design was FlorenceNightingale,whose

Notes nHospitals1859) s inscribedn theverydiscourseofa zymotic

theoryofdisease.In fact,herrecommendationsorthedistribution f

space, (1.,500) cubic,footper patientand 100squarefoot per bed),

were,according o the authorsof the 1955NuffieldHospitalDesign

study, maintaineduntil 1937 (see, Nuffield 1955:13).Indeed, the


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Thearchitecturef thehospital 95pseudonymousE andO.E'writingon hospitals or nfectiousdiseasesin 1936 recommended ven largervolumes of air in orderto prevent'stagnation'and consequent nfection(see, E & O.E. 1936).Space inthepavilionhospital s necessarily,hen,full of lightand air.The useof verandahs, o which patientscan be expelledduringthe hoursofdayligh-t,acilitates he circulation f airand staircasesn multi-storeyblocks are often placed on the outside rather than the inside ofbuildings or thesamereason.Insidethewardof thepavilionhospitalthekey dimensionsaremeasured n relation o the distanceof one bedfromanother, heheightof ceilings, he relationship etweenwindowsand beds (preferablyone window between each bed), and therelationshipbetween the observationpoint for nurses and thevisibilityof the patients (see FigureI). The children'sward of thePresbyterianHospitalPennsylvania, or example, (AmericanrchitectandBuilding ews1888)displaysall of these principlesn its octagonalvariantof the Pavilionplan.With the diffusionof 'germ theory' in the latter quarterof thenineteenthcentury,however,warddesignchangedso as to reflect heoperation of a new and revolutionarytheory of disease, whilsttraditional rchitecturaleatureswerereinterpretedn the lightofnewideas. The acceptanceof germtheoryfound its initial expression nthe sitingand designof the operating heatreandthe laboratory,butfrom thereit movedoutwardand into the wards.Its primary eature(especiallyas far as children'swardsareconcerned)was to be foundin the constructionand use of the isolationcubicle(utilizedso as tominimizecross-infection). n 1900, for example,the Ho^pitalasteurwas builtwith all of its bedsin isolationcubicles,thoughLesEnfants-Malades ad supposedlymade use of isolationcages as far back as1889. Isolationwardsfor babieswere developed n Vienna, Berlin,and Paris-each cot in a singlecubicle.Windows-once so centralto the flowof'fresh'air-were sealed andventilationcarriedout bymechanicalmeans.Glasswas now used only to isolate the differentinhabitantsof the ward in separatepartitions.And this new divisionof space which rapidlyfragmented he broad vision intrinsicto theconstruction f the Nightingalewardwasquickly akenup throughoutwesternEurope.In Sweden, for example, the emphasison isolationwasgiven expression ight up untilthe 1920s n the useof glass doorsand partitionsthrough which parents,visitorsand sometimesthepatients hemselvesmightsee, butnot contact hechildrenwithin (seeNuffield1963:9).The babies'hospitalof Philadelphia uilt 1919 (see,Ziegler 1923), was so designed that any hospitalvisitor exhibitingsigns of contagiousdiseaseto the clerkat the entrancedeskcould,andpresumablywould, be sentdown to isolationrooms n the basement.The isolationroomswere entirelycut offfromthe rest of the buildingand had exteriordoorsleadingdirectly nto the street'so that a caseonce sent to these roomsnever comesinto the buildingagain'.The


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, _ * _ __ t 8 t v , * * i1sI FIGURE l

X ,

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Thearchitecturef thehospital 97apparently it, however,weredirected o the first loorandthence ntoone of the many six foot high enamelledsteel booths, 'designedtoprevent cross-infectionamong the waiting patients'. Should thewaiting patients be eventuallyfound to require hospitaltreatment,theywere assigned to the sixth floor.

Thesixth floor s a cubiclefloor. . Thecubicles ace thesouth withthe NursesObservationRoomin the centerso arrangedwith plateglasspartitions hat the nurseon duty has an unobstructed iew ofthe cubicles and the porches n front of each cubicle at all times.The cubicles are arranged for one baby only and each has itsindividualbath,specialcrib andmetalwardrobe. Ziegler1923:98).In England,however, he fascination orisolation s supplementedand often supplanted by the perennial quest for fresh air andsunshine. The Belgrave Hospital for Children (1900), and theBirminghamChildren'sHospital (1918) had few isolationcubicles,though both were designed with at least one eye on the spaces inwhich fresh air could circulate.Neverthelessby 1930 one third ofchildren'sbeds in the LCC areawere sited in isolationcubicles.Sucha mixtureof design, reflectingas it does a conflationand confusionof

two theoriesof disease, was clearlyreflected n the writingsof 'E andO.E' (1936). Their hospitalforinfectiousdiseases s designed n twoparts.The first, the pavilionblock, as we have already discovered,wasdesigned n accordancewiththe principles f theancienre'gime, ndthesecond thecubicleblock in accordancewith theprinciples fthe new order.The fragmentation f the Nightingalewardtended to occur onlyafter the findings of bacteriologypointed the way toward a newetiologyof infection.This emphasisupon thetransmission f infectionwas, however, tself modified n the wake of a new disciplinewhichbegan to emerge n the firstfewdecadesof the presentcentury thestudy of child development.By the 1920s,forexample, the isolationprinciple, or childrenat least, is modifiedand begins to breakdownin the wake of psychology'squest to reconstitute he 'normal'childand itsdevelopment.Concern s expressed verthe problem hild andthesolitarychild, and popularFreudiannotionsof child developmentnot onlybegan to undermine he authoritarian ndregimented thosof ward management but to encourageopportunities or the self-expression f the childas well as for social ntercoursewithadultsandotherchildren.It is at this stagethat we first encounterwidespreaduse of the play room as an essential component of ward design,(though he first nstanceof a playroomas anintegralcomponent f achildren'sward probablyappeared n Buffalo,New York 1911;see,AmericanArchitect 1911)The L shaped wardof Great OrmondStreet(Fig II), forexample,can be seen to express many of the aforementionedprinciples.


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The rchitecturef thehospital 99Isolationunits forthe controlof infection, emperedby the provisionof twoplayrooms n whichchildrencaninteract though play' tselfhas a clearboundarydrawnaround t. The siting of theSister'sofficeis designed so as to facilitatesupervisionof nurses and control ofvisitors,whilsttheoverallproblemofobservationwhich is createdbythepresenceofsinglerooms s overcomeby the use ofglazedpanels nthe dividingwalls. A similar design is apparentin the children'shospitalHelsinki 1939 (see, Nuffield1963)Thesesameprinciplesare furtherdevelopedn the 1960s, hough na somewhatnovelmanner.Fornow the playroombecomesan openand readily visible play space (Fig. III) designed so as toincorporate he 'natural'activitiesof the child into an observationalweb.And onefurtherandsignificant ddition s madeto theward; heprovision f themother'sdivan. Thisprovisionoffacilities o continueand encouragemother/childbondingcould only have arisen in thepost-Bowlby ra and it is a farcry fromthe aforementionedwedishhospitalsn whichvisitingparentswereprevented romcontactinghechild except via glass partitions.Indeed, Bowlby (1953) cites withapprovalthe views of Sir James Spencewho, in his lectureson TheCare fChildrennHospitalrgued or theadmissionofbothmotherandbaby in thosecasesrequiringhospitalization.ForBowlby,everythingthat could be done to lessen the 'emotionalshock' of a hospitaladmission,must be done. As well as the admissionof motherswithchildren, iexiblevisitinghourswererecommended o as to encouragemother-child ondingandthe 'astonishingpractice'and'madness'ofseparating henewlybornchildfrom ts mother n thematernitywardwas severelycriticized.The desirabilityof encouragingparental inks is still evident n the1984 DHSS design documents(DHSS 1984a, and DHSS 1984b),and it is mixedwithan equallystrongdesireto avoidisolationunderanycircumstances.According o DesignBriefingSystem23,'Isolationin a single room can be a most disturbingexperience or a child'(DHSS 1984a:26)and only two beds out of 20 arerecommendedoradaptationto 'barriernursing'.Furthermore, he ward has now toprovidefacilitiesfor the full and completedevelopmentof the child.Provision for social, educational and recreational facilities, 'inaddition o medicalandnursingactivities' DHSS1984a:26),mustbeconsidered.And, in deference o the everwideningnetworkof healthcare,seminar acilitiesaresuggestedso as to providea base for'casediscussion'.Moreover,whilst the staffbase shouldact as the focalpoint for all members of stafTand sited so as to ensuremaximumobservation,a new and iniquitous ormof observation s introducedinto the ward theviewingroom, 'withone-wayviewingpanels. . .and recordingand listeningequipmentso that the activities of thechild can beobserved and recordedas required' DHSS 1984a:18).We can see, then, thatthe planof thechildren'swardencompasses


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The rchitecturef thehospital 101a seriesof theorizations oncerning he natureof disease, the child,paediatricmedicineandnursingpractices.Andthespecific eaturesofdesignincorporatedn each plan reflectquite specifictransitionsnmedicaldiscourse.But my argument s not simply that the plansreflectchanging heorizations f thechild as an objectof medicalandpsychologicalattention. I also wish to claim that the necessaryalterationsin the physical design of wards were instrumental nconstitutingthe objects of a discourse.Thus, the provisionof theisolationcubicle n the earlierpart of thecenturyhelpedto constitutethenatureofinfectionanddiseaseas ontologically istinctentities.Inthesameway,the provisionof a mother'sdivanhelpstoconstitute henatureof the 'maternalbond', the provisionof a play spaceor playroomhelps to constitute henatureof'normalchilddevelopment',heprovisionof the seminarroom aids in the constitutionof modernnursingpractice, ust as the provisionof the children'sward itselfhelps to constitutethe very nature of childhoodin the twentiethcentury.Of course,thereare many featuresof architecturaldesignwhichhave remainedapparentlyconstantduringthe last centuryor so ofward construction.The 1955 NufEeldstudyn or example,was asmuchconcernedwith the diffusionof light, the distributionof spaceper bed, and of the natureof wardventilationas was Nightingale nherNotes,but it is essential o underline he factthatthese featuresofphysicalenvironmentwerewoven nto entirelydifferentdiscourses ndisease and medical practice. Thus the space which Nightingaleassumed o harbourmiasmawaslaterassessed olely nrelation o therequirementsof nursing practice;the light which once facilitatedvisibilityof the patientwas later utilizedsolely in the war againstbacteria, and the ventilation once designed to dissipate noxiousvapourswasfinallyconstructedo as to minimize heflowof airbornestreptococci.IV. A DISCIPLINARY ARCHITECTURE: THE EARLY ASYLUMSWhilst the first children's wards did not demand a specializedarchitecturehe samecannotbe saidaboutthe firstasylums.Indeed,and according o such writersas Rothman(1971)and Scull (1979),the very hallmarkof madness was that it necessitateda specialarchitecture. orthem,the movefrommadhouseso asylumsmarkeda suddenand distinctrift in the organizationof deviantbehaviour.For Foucault,of course,the construction f theasylumsoccursduringthe era of the GreatConfinementn whicha newdisciplinarypoweremerges represented y a physicalenclosuren whichdocile bodiesaresubjectto constantsurveillance.In fact, it seems likely that the emergenceof such a specialized


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102 Lindsayriorarchitecturetandsnearthe openingof an erain whicharchitecture,n general,was usedas a weapon n thecontrolandcareof the body.entham'sdeason thePanopticon ndBarresplanofa manufactoryt Jouy, (to citejust two examplesof the genre), representdiversexamplesof this. And the emphasison the use of architecture oontrol bodily movementand emotion is evident in the variouseportswhichwereproducedon the plightof lunaticsin England.he 1815 Report, for example, included numerousplans for theesignof asylumsanddiscussednotjust mattersof cost but also themplications fbuildingdesignformattersofcontrol.The 1807reportncludedevidenceon design (albeitin rudimentaryorm)fromJohnash,andaccordingo Digby(1985)thedesignoftheRetreatatYorkookntoaccount heeffectsofarchitecturaleatures n thesensibilityfthe patients.It is undoubtedly he case thatConolly,regardednisday as one of the greatreformers f the asylum,laid particularmphasisn aspectsof physicaldesignin the treatmentof the insaneseeConolly1968).It is of interest, therefore,that despite diverse and somewhatontradictoryiews on the therapeuticregimeswhichwere appliedithinhe walls of the early asylums,thf architectureof madnessxpressed certainconstancy.In fact, it matterslittle whetherwexaminehe architectureof the Lunatic House at Guy's (seearliamentaryapers PP 1814-15), Bevan's plans for the LondonsylumPP 1814-15),hisplanofthe Retreat ThompsonandGoldin975),r, indeed,the plan of the New BethlemHospital(PP 1814-5). or,eachof theseplansexudeall of the elementsnecessary o aisciplinaryrchitecture:nclosureof the inmatesfromthe externalnvironmentnd the internal partitioningof space. And, moremportantly,n eachof the asylums he emphasis s uponsinglecells,r,t the very best, small rooms.The plan of the intendedLondonsylumevealsall. It is a superbexampleof the famousPanopticon.heings of the hospitalradiatefroma centralinspectiongallery.heub is populatedby the asylumsfunctionaries nd the entranceohewingsis controlledbyporters.Withinthewingsthemselveshemphasiss uponsinglecellsandit is thiscelland,stillmore,thebedithint which markedout the spatial unit in which disciplineperated.n fact, I wouldarguethat the emphasisuponthecell as auildinglockof theasylum s suggestiveoftwoprinciples: desire omphasizehe individualityof the occupant,and a desireto controlheccupant.Foucault,of course,emphasizes he importance f theattereaturein the constructionof modernbuildings,whilst moreecentesearchntothehistoryofconfinementseeBynumetal. 1985)endso laystresson theformer.Nevertheless,hefactthattheseearlysylumsere constitutedprimarilyas mechanismsof controlis, Ielieve,lainlyevidentwhen we comparethem with the designofnglishrisons(see, Evans 1984;Rosenau1970;Tomlinson1980)


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The rchitectureJ5theospital 103According o Foucault, heemergenceof the Panopticonmarks hebeginningof an era in which the hiddencontrolencapsulatedandexpressedn the darknessof the dungeon s reversed n the lightandvisibilityof thecentral ower,butwheretheexpanseof suchvisibilityis nothingmorenor less thansatrap'.For,in suchvisibility s hiddena new technology of surveillancewhich is ubiquitous and allconsuming.This contrastbetweenthe controlof the Panopticonandthatof thedungeon s, in somesense at least,broughtout in startlingfashion by the architecture of the Narrenturmt the AllgemeinesKrankenhause,Vienna 1784, Fig. IV). The architecture of theNarrenturms the veryoppositeof that contained n the Panopticon.The central block housing the staff togetherwith the curvilineardesignof thetowermake t impossible o seetheinmatesexceptwhilststandingdirectly n frontof theircells. Visibilityand surveillanceofall physical forms is thereby severely restrictedin the Vienneseasylum whilst it is omnipresent n the Londonasylum. Moreover,there is an equally importantcontrast to be drawn between theGeneral Hospital, the Panopticon,and the fools' tower. In theNarrenturmnd the Panopticonwe see only cells, yet in the centralHospitalwe see wideandspaciouswards,andthespatialdivisionsofthe institutionsare altogetherdifferent.Wardsforthe sick,and cellsfor the insane;the contrastcouldn'tbe greater.I wouldargue,then,that ifnothingelse,thesearchitectures regivingexpression owidelydifferenttheorizationsof the human conditionin illness and thehuman condition in madness. Furthermore,and according toThompsonand Goldin (1975) the inmatesof the Krankenhauseerecarefullyarrangedand categorizednto therapeuticgroupsInmates were classified according to disease: 'those with hotillnessesare placed together,as are the cold feverpatients, thedropsicalpatients,patientswith crabs,or scabies, or dysentery';therewas even a ward for 'thosebitten by maddogs'.Convalesc-ents werecompletelyseparated romotherpatients,and venerealdiseasesweresegregatedwhereno strangerwilleverbe allowedtocome'.Withindiseaseclassifications atientsweredividedby sex.One moredivision runs throughthe whole hospital. . . Patientswere strictlydivided by ability to pay. (Thompsonand Golding1975:1 3)Yet in theNarrenturmivisionand classificationadeto the narrowwidth of thesinglecell thereareno wards n the fool'stower.Thisis not to arguethatclassification layedno part n thesocialworldsofthe firstasylums.We knowall toowell fromthe plansof suchplacesas theGlasgowAsylum,(see,ThompsonandGoldin1975),and fromthe writingsof Conolly, Tuke and others that classifications ameto forman integralpartof therapynsee, Scull 1980)but there is nodoubt andthearchitectural lansevidence his thattheunits of


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Thearchitecturef thehospital 105the classificatoryystemweredifferent. n the fool'stowersthe baseunitwas thecell. In fact thecommondenominator f the planswhichrestbeforeus is not, as Foucaultargued,the technologyof visibility,but the technologyof individualizationand physicalcontrol.Thefocus was on the inmate as an object of controlratherthan on adiseaseamenable o therapy,andone suspects hat the earlydebatesover restraintwerenot so mucharguments oncerning estraintandnon-restraintbut ones concerningthe mechanisms(mechanicalorarchitectural)best suitedto the function.This emphasisupon the control capacitiesof the single cell isclearlyevident n the writingsand approvedplansof oneof thegreatreformers f the asylum,John Conolly.In fact, forhim classificationand segregationwere about the most importantthings that theasylum could achieve;a controlledenvironment.Nevertheless,hefirmlyargued hattwo-thirds f the asylum'snmates houldalwaysbecontainedn singlecells andthatdormitorieshouldonly everbeusedfor weak and timid patients (see, Conolly 1968). Moreover,thisemphasisupon singlecells is evidentat least until 1847when thereportof the LunacyCommissionersnto HaydockLodgeAsylumnotedwithdisapprovalhe replacement fthe cellwith thedormitory.In theasylumthecell was the preferredmodeof containment nd thedormitorywas acceptableonly for the asylum'shospital.Medicinedemandeda differentarchitecture rom confinement,even thoughfinancialcostwas to leavethedemandof the latterunfulfilled.n factthe cell and the dormitory haredonlyone common eature.It was afeaturewhich servedas a lynchpinof the entiresystemand it was todominatehospitaldesign at least until the early 1970s;it was, ofcourse,theibed'.Controland segregationwere not, however,the only functionsofdisciplinarypacing.For f wereturn o ourplanswe cansee inscribedin the draughtsman'snk the elementsof a wider discoursewhichsought,and still seeks, to regulatebodilyfunctions.The bathrooms,dayrooms,airinggrounds,wash-houses,bed-rooms,pellout in somedetailtheelementsofa culture n whichthebodyandits functionsareclosely regulated. Such a close discipline of the body and itsmovements s equallyevidentin the plans of the wards for childrencited earlier,and will be seen once more in the modernplans forpsychiatricunits. Such a division of space and time accordingtobodily functionand the principlesof privacy, s perhapsone of themoststriking eaturesof theseplans andit is a featurewhichmarchesclosely n stepwith the developmentofwesterndomesticarchitecture(see, Stone 1977andBrown1986).In fact,we see beforeus a historyof the bodyas wellas a historyof illnessanddisease,forthe buildingsrepresented y theseplansconstituteourmodernmageof bodilycareand organizationust as surely as they constituteour image of thechild or the lunatic. Finally,we see expressed n this architecture


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106 Lindsay riora nascent division of labour. Space within the asylum is distributedaccording o one's place in the hierarchyof labour,and volume andstatus overlap so as to ensure that those who inhabit the higherechelons of the disciplinaryapparatusobtain the largest amount ofspace. The greatest amounts of space to supervisors, ess to thekeepers,yet still less to the menialfunctionaries. t is an architectureof social hierarchy which echoes throughout the nineteenth andtwentieth centuries, and serves to underpin the strict division oftasks which define modern medical practice. However, as madnesstransposed nto illness throughout he nineteenth-centuryhe archi-tectureof the asylumcame to approximatemore and more to that ofthe general hospital. The diseased mind came to be contained inwards, and with the birth of psychiatryproper space was brokendown according o differentcriteria.The disease model of madnessreceived ts imprimaturn the 1908reporton the Care and Controlofthe FeebleMindedwhich recommendedhe deletionof the conceptofasylum and its replacement with that of 'Hospital' The reportcontained numerousplans for the design of the new hospitals andincludedamong them was that for Purdysburn ospitalbuilt on theoutskirtsof Belfast-the design unmodified o this day. The divisionof space according o bodilyfunction,and the spatialexpression f thedivisionof labour s still evidentbut the pivotalfeatureof the asylum-the cell-has long disappeared.V. THE PSYCHIATRIC UNIT AND THE COMMUNITY I973-I 982It is somewhatparadoxical hat I choose to open this discussionofmodern psychiatricpractice by referring o a plan which containsalmost nothing but cells. It is the plan of the Towers HospitalLeicester DHSS 1982).As a securityunit one would, perhaps, xpectit to be dominatedby single cells and carefulcontrolof entrancesandexits, but what is more interesting is the manner in which thebuilding serves to regulate the body and bodily activity. The bedroom, the living room, the dining room, the bath room, the lavatory,the games room, the interviewroomjand the waitingroom, all serveto signify he manner n which bodilyactivity s dividedand regulatedthroughspace/time categories.Equally interesting s the manner nwhich the division of space reflectscurrentpractices n psychiatriccare-the rooms for social workers and occupationaltherapistsannounce, at the very least, their presence n the networkof care,whilst the seminarroompays homage o the demand or some formofcollective discussion on matters psychiatric.And, finally, the planexpressesthe manner n which access to the premises s structuredaccordingto fundamental ocial (patient, staff, visitor) and gendercategories.


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108 Lindsayriordisorder.Thiswillnormallybehelpedby providing inglerooms nthe high nursing dependency area, multi-bed rooms in theintermediate nursing dependency area and multi-bed roomsdivided into cubicles in the minimumnursingdependencyarea(HBN.35:22)The high nursingdependencyroomsshould,of course,be locatedcloseto the staffbase,and the provisionof an annexis suggested orthoserequiringa highlevelof observation.The numberof entrancesand exits within the buildingshould be minimalso that effectivecontroland supervisionof patientscan be 'maintainedat all times'.Though the intermediatepatientsshouldbe encouraged o use theday hospital n theirprogress owardrecovery.The day hospital should occupy a separatespace from the in-patientarea.Its orientationhouldbe 'outwardooking'.Facilities orcommunitybasedsocialworkers houldbe provided, demonstratingthe existenceof the marriagebetweenhealthand socialservices)aswell as provisionfor a staff seminar/conferenceoom. The latterpresumablydesigned so as to encouragethe therapeuticteam inwhichnurse, social worker,and psychiatristdevelop a commonstrategyor the careof each 'client'.The furnishings f the hospitalshouldbe domesticand not institutionalized,hus maintaining heechoof that 'community'whichis assumed o lie beyondthehospitalwalls.And,withsomenotableexceptions, suchas theprovision fanECT uite),thescheduleofaccommodationn both n-patientandthedayhospitalreflects he sameconcernwith the categorization f thebodyand the elementsof its controlas does the secureunit at theTowers ospital.Hence, includedin the schedulefor the in-patientarea s the following:entrance, bedroom, w.c.'s, bathroomandshower, atients'utility room, beauty room, day room, quiet dayroom, ursery, taffbase (placedforcloseobservation f bedrooms),nursingffice,consultingand interviewingroom,store, staff toilet,visitorsaitingroom,andvisitors' oilet.Whilsttheprovisionortheday-hospitalxpressesa closerrelationshipbetweenpsychiatryandthegentsof'communitycare'thus:Receptiondesk(placedso as tofacilitatebservationof the main entrance to the department);Admissionnd recordsoffice;Nursery;Patients'cloakroom;Centraldiningoom; Occupationaltherapy suite; Rooms for group andindividualherapy;RoomsforBehaviourTherapy;ECTsuite;SocialWork fEce;Local authoritybase; Clinical Psychologist'sOffice;Interviewingoom; Consultingroom; Patients' toilets (male andfemale);tafftoilets (maleand female)It is clear,however,that evenwithinthe reassessment f hospitalaccommodationhat Building Note 35 represents, there is nochallengeo the assumption hat in-patientpsychiatriccare shoulddominateuildingprovision.Yet, within the space of 10 years the


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The rchitecturef thehospital 109assumptionsn whichBuildingNote 35 was itselfconstructed ereradicallyreappraisedn a systematicmannervia the WorcesterDevelopment roject DHSS 1982 henceforthWDP 1982).TheWDP took ts lead from he 1975WhitePaper,Better ervicesor theMentally11 DHSS 1975), in whichthe virtuesof community sopposedo hospital areprogrammesereextolled, nd thus beganto analyse rangeofaccommodationuitableorthe mentallyll. Inmanyrespects he reappraisaleflected remarkableevolutionnattitudesowardpsychiatricare.Indeed, heWDP 1982documentactually uestionshewisdom fbuilding p a psychiatricervice nthe foundationsf a hospitalbaseddepartmentf psychiatryinceany suchdepartments likely o dominate heprovision f services.Furthermore,he document hallengeshe wholebasis of hospitalarchitecturey questioninghe suitability f the'bed'as a buildingblockoftherapy nd treatment,for, n a worldn which he patienthas been replacedby the 'client'and 'illness'by 'behaviouraldisorder',he bed is made redundant). ndeed,observation ndassessment f behaviouralisordersan onlybe made 'in real lifesituations', nd thereforehe clienthas to be integratednto suchsituations s well as into 'normal' omestic ettings.Evenwhereahospital sychiatricnithasto bedeveloped,armore domestictylefurniturend ighting'houldbe providedWDP1982:15). utbetterstill wouldbe the provision f day hospitalswhich shouldavoiddominationy the ECTunitandshould eek odevelop n'intimatedomestic tmosphere' HBN.35is criticizedornot recommendingthis. Overall, hen, the move to communityare demands movetowarda communityarchitecture, nd this emphasisupon thedomesticityf settings ndcommunityrientationf organizedare salso muchin evidencen otherreportson the psychiatricerviceproduced uring ecentdecades uchas, forexample, theReportnOrganisationalndManagementroblemsfMentalllness ospitalsDHSS1980), the Report nPsychiatricospitalsn NorthernrelandDHSS1979),andtheReview ommitteenServicesforheMentallyll (NorthernIreland) DHSS1984).In additiono hospitalbasedpsychiatric nitsand dayhospitals,however, he emphasisupon communityhas also required heprovisionf day centres.The daycentre xpresseshe apotheosisfcommunitysychiatry.t is a buildingwhich s intended o act as anodalpoint or inksbetweenheclientandhisorhercommunitynd,according o the reassessmentontained n Better ervicesor theMentallyII it shouldbe firmlyentwinedntothe social ifeof thelocality nwhich t is based.The building pproved y theWDPas aday centre,for example,'is not obviouslydifferent romotherpropertyn the street(WDP 1982:24), nd the report urthertatesthat


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110 LindsayriorIn general heWDP (day)centre hathasproved hemosteffectiveesignforthe servicebeingprovided s the Worcester entre.Theuildingis generallydomesticin scale and characterand has aomesticstyle enclosedreargardenwhichis privateand secludedespitethe city centrelocation.(WDP 1982:21)Therearefewdistinctarchitecturaleatures n the day centreandhe building bears little similarityto the hospitalsto which it iselated.In one sense it is clear that a programmeof decarcerationequiresa new and revolutionaryarchitecture or the mentallyillhichs a mirrormageof thatwhicharoseduring heeraofthegreatonfinement.ndeed,eversincepsychiatricllnesshas beenregardedsubiquitousn the populationat large(seeGiel 1983),the rationaleorhospitalbased ratherthan communitybasedtherapyhas beeneverelyunderminedand with it has gone the rationalefor thesylum.It is, perhaps, a strong and fitting reflection of theeassessmentfmental llness n thecommunityhatDHSSarchitectsaveevelopedplansto developnewcommunitiesn andaround heldnineteenth-century sylums and thus affiliatethe behaviouralisorderithoutto the disorderwithin.VICONCLUSIONSI have arguedthat the spatial divisionswhich are expressed nuildingsanbebestunderstoodn relation othediscursivepracticeshichredisclosed n their nteriors.The architecture f hospitals s,herefore,nextricablyboundup withthe formsof medicaltheorizingndmedical practice which were operant at the hour of theironstructionnd, what is more, all subsequentmodifications oospitalesign can be seen as a productof alterations n medicaliscourse.s a corollary of this I have further argued thatrchitecturaleatureshaveno existenceoutsideandbeyond heformsfhought nd practicewhichproduced hemandthatit is thereforerroneouso speakofthe 'logicofspace',orofspatialpropertieswhichrendependentof observersand actors (c.f. Hillier and Hanson984).ut thisis not to say thatspatialdivisionsandcategorizationsaveo be 'activated'by consciousagentsbefore heyenterinto theorlds social phenomena.The appropriation f space in humannteractions not a sine qua non forthe manipulation f physical orm.pacend spatialcategorizationsxistin theirown historyand theyonstrainndrestrict,aswellas reflectandconstitutevarious ormsofocialctivity.To comprehendhathistoryand to understandhoseonstraintshey need, above all, to be analysedin terms of theoncepts,heories, ieldsofthoughtandhumanpracticen whichtheyrembedded.n linewiththesedemands,I haveattempted o show


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The rchitecturef thehospital lllhowthe paediatricwardreflectsandconstitutes lementsofpaediatricpractice;howthe PsychiatricUnit reflectsandconstitutes lementsofmodern psychiatricpractice;and how the asylum reflectedandconstituted heessentialelementsof a theoryofmadness.In fact, andin orderto analysethe internaldivisionsandformsof categorizationwhich are expressed n the ward,the cell and the hospitalwe mustturnneither o thecomputernor to the conscioushumanactor,but tothe complexfieldsof humanthoughtand practicewhichare utilizedin the very interiorswe seekto study.

LindsayriorDepartmentfSociologyndSocialAnthropologyUniversityf Ulster tJordanstown

BIBLIOGRAPHYAmerican Architect and BuildingNews. 1988. 'Children'sWard of thePresbyterian Hospital Philadelphia'.AmericanrchitectndBuilding ews24:76.American Architect and BuildingNews. 1911. Children's ospital.Buffalo.NewYork'AmericanrchitectndBuildingNews100: 868.Armstrong, D. 1979. 'Child Develop-mentandMedicalOntology'. ocial cienceandMedicine3A:9-12.Armstrong, D. 1985. 'Spaceand Timein BritishGeneralPractice'.Social cienceandMedicane0:7:659-66.Bhaskar, R. 1975. A RealistTheoryfScience. eeds.LeedsBooks.Bourdieu, P. 1973.iTheBerberHouse'in M. Douglas, Rules and Meanings.Harmondsworth:enguin.Bowlby, J. 1953. Child Careand theGrowthfLove.London.Penguin.Brown, F. E. 1986. 'ContinuityandChangein the Urban House. Develop-mentsin DomesticSpaceOrganisationsin Seventeenth-Century ondon'. Com-parativetudiesn SocietyndAlistoy28:3:558-90.Bynum, W. F., R. Porter andS. Shepherd. 1985-.TheAnatomyfMad-ness,Essaysn the IIistory f Psychiatry.Vols. London:TavistockPublicationsConolly, J. 1968. (Orig. 1847) TheConstr7>ctionndGovernmentfLunaticsylums.London:Dawsons.

Digby, A. 1985. 'MoralTreatmentattheRetreat?796-1846'n W. F. Bynum,R. Porter,and S. Shepherd,op.cit.Durkheim,E. 1915.TheElementaryormsof theReligious ife.Trans.J. W. Swain.London:GeorgeAllenand Unwin.Durkheim, E. and M. Mauss. 1963.(Orig. 1903). Primitise Classification.Trans.R. Needham.London:CohenandWest.D.H.S.S. Welsh Office. 1973.HospitalBuildingNote. Departmentf PtychiatryfMentalllrzss)or aDistrict eneralospital.Number35. ondon:H.M.S.O.D.H.S.S. 1975. BetterServicesor theMentallyIII (Cmnd 6233). London:H.M.S.O.D.H.S.S. 1979. PsychiatricIospitalsnNorthernreland. Surueyf PhysicalacilitiesandEstimatesf FutureDemand.Belfast.H.M.S.O.D.H.S.S. 1980.OrganisationalndManage-mentProblemsf Mental llness Iospitals.London:H.M.S.O.D.H.S.S. 1982. Mental IealthBuildingsEualuationamplet. Worcester)evelopmentProjectsychiatricrovision WhereoWeGoFrom Iere?.London?DHSS WorksGroup.D.H.S.S. Northern Ireland. 1984.ReviewCommitteenServicesortheMentallyIII. Mental Iealth The WayForward.Reporton the MentalAlealthService nNorthernreland.UnpublishedReport)


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