Description

The history of hospitals has been shaped over many centuries by a multitude of civilisational factors: social, political and economic changes along with advances in medicine and medical knowledge have all influenced the development of a building type dedicated to care and healing to varying degrees.

Religious orders as providers of care

In the Middle Ages, the hospitals, pest houses, almshouses and orphanages administered by Christian orders were not just institutions of religious charity but were facilities for caring for the sick and protecting other citizens against dangerous communicable infections.

The importance of these institutions became particularly apparent in the 15th century when successive waves of dangerous epidemics such as leprosy or the plague swept through Europe. Isolating and treating infected persons in these buildings made it possible to contain these diseases without impacting excessively on the increasing mobility of the population. The hospitals were usually built outside the city walls or on the outskirts of a settlement to limit the spread of infections (Figure 01). Helping and healing the sick and infirm was typically the province of religious orders acting in the spirit of Christian charity. The building complexes serving this purpose were frequently self-contained walled exclaves at the edge of settlements (Knefelkamp 1987). Their close proximity to the church reflected the Christian ideal of spiritual and religious healing of the sick. For centuries, the St. Gallen Monastery Plan of the Benedictine Order, created around 820, served as an ideal model for hospital construction (Figure 02). The ground plan featured a quadrangular cloister that provided a direct path to the church and around which the social facilities were arranged. These included not only the dormitories for the friars, pilgrims and travellers, but also nursing facilities for the sick. The status accorded to care for the sick in the Benedictine monasteries was so important that the monasteries advanced to become centres of medical knowledge.

The Charité hospital in Berlin, completed in 1727, represents a milestone in the history of hospital design. The threat of plague epidemics and the fear of the ensuing social, economic and political consequences prompted Prussia’s King Friedrich I to build the hospital modelled on the Hôpital Saint-Louis (1607) in Paris. In addition to nursing wards for 200 patients, the Charité also had two infection wards and an obstetrics ward. The distribution of spaces was innovative for the time: the first and second floor wards had small room units with 10–12 beds, marking a departure from the hall-like infirmaries that had been common until then (Figures 3,4). The rooms were accessed from a corridor running along the inner wall facing the courtyard. The nursing staff supervised the daily routine and ensured that the rooms were kept clean and bed linen was changed regularly. The opening of the Charité marked the beginning of the founding of a number of other clinics in Germany from 1770 onwards dedicated to the provision of health care and support for poorer sections of society. The design of this first generation of hospitals attempted to find hygienic solutions for the construction of various types of buildings. The aim was to prevent patients from infecting each other in order to avoid, or at least hinder, the occurrence of hospital epidemics, a problem that was already known at that time.

The period of enlightened absolutism in Central Europe marked a very significant period of hospital development. Advances in research in the natural sciences had a lasting impact on understanding medicine, and from the 18th century onwards the field of medicine grew ever better at classifying diseases and developing successful therapeutic approaches. Hospitals were especially crucial for the well-being of the less privileged classes to protect them from infirmity and disease, especially as increasing industrialisation during the Age of Enlightenment led to a perilous deterioration of the living conditions of the working classes.

It was during this period of major upheaval that a large hospital was built in Vienna, which at that time had 250,000 inhabitants. Completed in 1780 to the plans of the physician Joseph Quarin and the architect Matthias Gerl, it aimed to centralise and rationalise care of the sick for an entire region. The buildings had three storeys, each with two wards that were combined into one unit. Each hospital room had 20 beds, which were placed along the two longitudinal walls below the windows. As such, there was no corridor along the side and the rooms were entered from the ends.

In 1785, Prussia’s King Friedrich II commissioned the construction of a new Charité hospital in Berlin. The new building was to have three wings, each with four storeys. A central axis divided the building into two sections: the rooms to the left of the entrance hall were reserved for women, those on the right for men. On the ground floor were the surgical and the internal medical wards. The nursing wards were located on the floors above (Figure 07). Smaller hospital rooms were arranged in the side wings, while the middle wing of the building, facing the street, contained wards for 16 patients each. Between each pair of wards was a sanitary zone and toilet. The building structure of the Charité also reflected the ongoing expansion and differentiation of medicinal disciplines since the beginning of the 19th century, and there were already eight independent clinics on the site at that time.

Pavilion layout providing patients with light and air

The period up to the foundation of the German Reich in 1871 is considered a transitional period in the history of hospital development. Hospital structures and equipment were changing constantly, and hygiene was increasingly becoming the focus of attention. Sanitary facilities were expanded, and washhouses were constructed, such as the one for the Charité in 1848 (Figure 08). At the same time, scientists began to address hygienically relevant topics such as the proper disposal of general and medical waste or the concerted cleaning of sanitary facilities, floors and surfaces. Hospitals were built that offered a high degree of spatial variability, making it possible to separate patients according to type of illness, sex and age, as well as to improve the quality of nursing care.

In the period between 1870 and 1918 the number of hospitals in Germany grew rapidly. Between 1876 and 1900 alone, the number of hospitals more than doubled from 3000 to 6300 and the number of beds rose from 150,000 to 370,000 (Murken 1988). At the same time, a surprising variety of hospital types emerged. One of the most important aspects of the new wave of hospital construction activity was the prevention of the transmission of hospital pathogens, resulting in so-called nosocomial infections. In addition, many hospital operators strove to offer patients better quality care during their stay in hospital, for example with respect to bed comfort, sanitary facilities and nutrition. This also led to a reorganisation of the design of hospitals. Instead of the corridor-type hospitals that had previously been built, freestanding pavilions were built on open ground. Small, low-rise buildings with patient wards were loosely distributed over a large area, their architecture more reminiscent of resorts and hotels than hospitals. Patients lay in wards with large windows, wide verandas or terraces. Priority was given to ensuring hospital beds had fresh air and sunlight and to maintaining a supply of clean air to the rooms. These structural changes to the design of hospitals were accompanied by advances in the fields of hygiene and bacteriology. One of the largest pavilion complexes of this period is the Städtisches Allgemeines Krankenhaus (Municipal Hospital) in the Hamburg district of Eppendorf, which opened in 1888 (Figures 09, 10).

However, by the end of the 19th century the pavilion structure was increasingly abandoned in favour of more densely-built, multi-storey constructions. Wards were arranged about corridors and hospitals were structured in smaller sections and spread across more storeys, resulting once again in taller buildings such as the Municipal Hospital in Düsseldorf (Figures 11, 12).

The principle of access to fresh air was, however, maintained and almost all of the wards opened to the south and were equipped with a large south-facing balcony. This type of hospital, known as terrace hospitals, was common throughout Germany until the Second World War (Murken 1995).

The changing hospital landscape after 1945

After the end of the Second World War, hospital construction in Germany began to develop in different directions. A common priority, irrespective of size of the hospital or clinic operator, was to increase efficiency through rationalisation. From the mid-1960s onwards, high-rise construction began to displace low-rise hospital building. An important basis for these structural changes were the scientific advances made after about 1950 in the field of antibiotics research to combat infectious diseases. The resulting continual decline in infections led a reduction in the number of patient rooms needed, and the combination of a shortage of skilled nursing staff and successful advances in medicine (e.g. artificial dialysis, heart-lung machines) meant that centralisation and automation now determined the direction of hospital design. Business management aspects began to play a more significant role. At the beginning of the 1960s, an efficient hospital would ideally have 200 beds or more, while an optimal nursing ward comprised between 25 and 35 beds. Centralisation also meant that workplaces were merged where similar or sequential tasks had to be performed. The progressive rationalisation of the German hospital system in turn led to a standardisation of individual hospitals according to capacity and number of beds, and since the 1970s, four categories have dominated the hospital landscape: hospitals with 200 beds provide a basic level of care services, those with 300–400 beds a standard level of services, with 600 beds central care services and those with 1,200 beds or more maximum care provision.

For the nursing sector, a double-corridor configuration was increasingly adopted, greatly increasing functional flexibility. Inward-facing rooms, located between two parallel corridors, were partially lit and ventilated by inner courtyards within the building. The double corridor system also made it possible to separate the circulation of visitors and patients.

The shift from a humanistic-holistic healthcare focus to a high-tech system is best seen in the so-called university clinics that were established in Germany from the 1960s onwards. The very high requirements in terms of economy, care, hygiene and medical technology that they had to fulfil resulted in highly technical hospital buildings. This development also paved the way for intensive care provision, which was centrally located in separate intensive care units. These technically elaborate rooms were used to treat seriously ill and newly operated patients, who were constantly monitored and supervised by a variety of measuring and other equipment. The university clinics with their three pillars – teaching, research and health care – very quickly became the most important source of innovation in clinical medicine where new research results could be put directly into practice. The rapid expansion of the university clinics came in response to a recommendation by the German Council of Science and Humanities in 1960 to increase the number of beds in the 18 medical faculties in Germany from 16,500 to 25,700.

A notable example is the vertical solution developed by the architects Benno Schachner, Peter Brand and Wolfgang Weber in 1973 for Münster University Hospital. Their solution is based on the by then already common model of a broad three-storey base for central diagnostics and treatment that connects vertically to two ten-storey towers with nursing wards, and horizontally to the teaching building and the care centre (Figure 13). The towers with the patient rooms are cylindrical in form and are arranged so that two circular wards connect to a square central area.

The circular ward configuration made it easier to keep an eye on patients and minimised travel distances for the nursing staff. Glazed sections in the patient room doors also afford visual contact between the patient and the nurses’ station in the middle. Each floor comprises two circular wards with 28 beds each, divided into two- and four-bed rooms. Each patient room has its own sanitary unit with toilet, shower and washbasin on the outside wall and between two patient rooms (Figure 14).

New challenges

Since the early 1990s, the German hospital system has faced several new challenges. Since 1993, the length of stay in hospitals has been shortened by a third as a result of the introduction of the DRG (Diagnosis Related Groups) system, a flat-rate billing procedure based on the classification of similar hospital treatments and diagnoses. In addition, both privatisation and specialisation have advanced significantly, and the proportion of privately funded hospitals is steadily increasing. Accordingly, the share of public hospital operators had fallen to below 30 % in 2008 (Ernst & Young 2010). While shorter hospital stays and fewer patients due to improvements in medicine have freed up hospital capacities, hospitals are increasingly competing for patients. The design of hospitals has had to adapt accordingly, particularly with regard to flexibility, adaptability and speed of reaction as the basis for long-term economic success. Modern hospital buildings need to be flexible and sustainable.

A further response to changes in society and healthcare that has been the subject of discussion for some years now is the concept of “Healing Hospitals” in which the architecture contributes positively to the patient’s recovery process (Meuser, Schirmer 2006). The hospital is gradually evolving into a place of convalescence with recuperative and recreational components more commonly seen in leisure facilities. We are seeing a gradual convergence of the building types of the hospital and the hotel. One example of this is the district hospital in Agatharied, Bavaria, planned by the architects Nickl & Partner. It provides contemporary medical healthcare in an attractive architectural context situated in an idyllic landscape, and its atmosphere is more akin to a comfortable hotel than a hospital (Figures 15-17).

Bundesministerium fur Gesundheit (BMG), Einnahmen und Ausgaben der gesetzlichen Krankenversicherung, KJ I Statistik, as per 27 May 2014

Ernst & Young, Krankenhauslandschaft im Umbruch, Stuttgart: Ernst & Young, 2010, p. 9

Ulrich Knefelkamp, “Die Heilig-Geist-Spitäler in den Reichsstädten”, in: Müller, Rainer A. (Ed.): Reichsstädte in Franken, Munich: Haus der Bayerischen Geschichte, 1987

Axel Hinrich Murken, Vom Armenhospital zum Großklinikum: Die Geschichte des Krankenhauses vom 18. Jahrhundert bis zur Gegenwart, Cologne: DuMont, 1995, p. 217

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Wolfgang Sunder, Jan Holzhausen, Petra Gastmeier,

Andrea Haselbeck and Inka Dresler, Bauliche Hygiene im Klinikbau. Planungsempfehlungen für die bauliche Infektionsprävention in den Bereichen der Operation, Notfall und Intensivmedizin (Zukunft Bauen – Forschung für die Praxis, Band 13), Bonn: Bundesinstitut für Bau-, Stadt- und Raumforschung, 2018

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Originally published in: Wolfgang Sunder, Julia Moellmann, Oliver Zeise, Lukas Adrian Jurk, The Patient Room, Birkhäuser, 2020.