Dr. Sarah Hartley
APHP Hôpital Raymond Poincaré, Garches, France
|Episodes from the Life of a Bishop Saint,
c. 1500 – Master of Saint Giles and assistant
National Gallery of Art, Washington, DC
With cathedral Notre-Dame de Paris, Saint-Jean-le-rond on the left and the hospital Hotel-Dieu in the background.
Until I left England to work in France, it had never occurred to me that the architecture of a hospital was intimately linked to geography and that its cultural history was literally written on its walls. Walking around Parisian hospitals, usually with a hospital plan in my hand in a desperate attempt to find a specific department, aroused my curiosity. French architectural styles seemed quite exotic and their ground plans quixotic. I began to wonder why.
Parisian hospitals, like those in many European capitals, are the results of years of accretion. Hôtel-Dieu, the oldest Parisian hospital, was founded by Saint Landry in 651 and was the only hospital in Paris until the Renaissance. The 7th century saw the founding of many hôtels-dieu across France: establishments attached to religious foundations, whose purpose was to house pilgrims but also to care for those whose illness made it impossible to continue their travels. Over time the hôtels-dieu focused on treating the sick, although the Hôtel-Dieu in the center of Paris remained open to all who sought care: the sick, travellers, pregnant women, the old, and the indigent. Following the motto of Saint Landry medicus et hospes (host and doctor), the staff even admitted lepers.
From the 7th to the 19th century, the chapel was the centre of every hospital, where the prayers of the faithful were considered the cornerstone of healing. To this day, older Parisian hospitals remain focussed on the chapel, from which the rest of the hospital extends, often in the form of a cross. In medieval times, the Hôtel Dieu in Paris refused no-one and during epidemics was often so full that patients had their mattresses placed in the corridors. Hospital overcrowding is far from a recent phenomenon. As a result of the need to enlarge, change site, and thanks to repeated fires in the 18th century, Hôtel-Dieu was rebuilt several times. The concept of symmetrical buildings with surrounding greenery was retained, a style found across Europe: the Ospedale Maggiore in Milan, constructed in the early 17th century being a good example. The Hôtel-Dieu of today was built in the 19th century, but the importance of the chapel has been conserved and is underlined by architectural device. The chapel is at the end of the rectangular formal garden, flanked by galleries behind which the hospital wards are hidden, and fronted by an impressive set of steps. A double arcade on the ground and first floor leads to the great arched entrance, which rises to the full height of the building. Windows close in the arches on the ground floor, although these do little to reduce the cold in the winter. Above, a further set of arches on the first floor has been left open to the weather, and a bridge connects the two sides of the rectangle, making a useful shortcut for staff willing to brave the freezing temperatures in the winter. The harmony of the setting is somewhat diminished by the statue of Guillaume Dupytren in the garden, which twice a year is dressed up by future medical students.
The initial hôtels-dieu not only housed pilgrims, but also protected them on their journey, and their protective role was symbolized by a high wall surrounding early hospital sites. The wall often had a single door, opened only at visiting hours. These doors were still in use in this century, and my patients relate that until the 1960s friends and relatives would queue up in the street outside the hospital door, waiting for the start of visiting hours.
As hospitals became larger, the idea of separating different types of patients emerged. Sub chapels radiated out from the central chapel, each with its surrounding wards. In order to allow patients being transferred from one section to another, galleries were constructed. Colonnaded galleries recalling cloisters are common, and were still being constructed in the 19th century. In other hospitals, tunnels (constructed using a cut and cover technique) connected the different sections, affording some protection from the weather. These tunnels are still in use in my hospital, despite being wet and poorly maintained. At least our tunnels are safe, unlike those of some other hospitals.
Louis XIV made town councils responsible for running hospitals—a heavy responsibility considering the many sick, beggars, and orphans at the time. He also encouraged founding new hospitals, such as the Salpêtrière, designed by Libéral Bruant in 1656. As these newer hospitals were supported by the wealthy, they were often constructed in a style recalling the chateaux of their founders, and the Salpêtrière is no exception, although little remains of the original buildings apart from the octagonal chapel. But new hospitals built around 1770 are impressive, their large wings radiating out from a triple arched entrance and the dome of the chapel rising behind. The Salpêtrière was not in its initial incarnation a hospital in the modern sense: it looked after the poor, but the sick were sent to Hôtel-Dieu. By the eve of the revolution the Salpêtrière, the biggest hospice in Europe, with a reputation for repression and ill treatment, housed over 10,000 people, with an adjacent prison containing another 300.
The disruption caused by the Revolution of 1789 left the civil hospitals in a deplorable state. The Directoire and subsequently Napoleon Bonaparte tried to improve the situation by restoring confiscated wealth and creating national institutions catering for the blind and the deaf. Civil hospitals numbered about 2,500 at the time, but were mostly small institutions which catered to the poor, the old, and the destitute as well as to the ill. Military hospitals were also developed, and tended to be large, symmetrical and of neoclassical design.
Pasteur’s championing of the concept of hygiene in the mid 19th century encouraged the construction of pavilions—isolated buildings that limited the spread of disease. They were often scattered about the hospitals grounds, connected by covered walkways. As medical specialization slowly emerged, pavilions allowed patients to be organized by pathology. Pasteur’s ideas were echoed in England, where Florence Nightingale in her Notes on Hospitals wrote of the importance of fresh air and light. Wards were constructed with high ceilings to allow for the circulation of air, and with large windows to admit as much light as possible—essential when daylight was the strongest light available.
Fresh air and light were difficult to find in the dense urban landscapes of 19th century France, and so hospitals began to be sited away from urban centers: a good example is my own hospital, the Hôpital Raymond Poincaré, situated in the suburbs of Paris on a hillside facing a park, whose first buildings were constructed in the mid 19th century. The chapel is still a central feature, linked by covered walkways to wards contained in large classically inspired blocks. Initially a hospice dedicated to the relief of the poor like the Salpêtrière, the Hôpital Raymond Poincaré was transformed into a hospital in the modern sense just in time for the Second World War. As with other rural hospitals, its setting has been transformed into a suburban one as Paris has spilled over the boundaries that contained it for so long and engulfed the countryside around it.
In the years before the Second World War, new pavilion hospitals were being built: good examples being the Military Hôpital Percy, in the South of Paris, with 24 pavilions finished in 1920 connected by galleries, or the Hôpital Avicennes in the north, constructed for the Muslim population, which retains a splendid entrance gate inspired by oriental architecture, decorated with blue tiles. Percy was rebuilt in the 1960s but Avicennes retains much of its original details. Three large, three storied red brick buildings at Poincaré date from the 1930s, with architectural details typical of the period, and are linked by a tunnel. Each block has a central spine from which narrow wards project. The wards have high ceilings and large windows but the original large wards have been subdivided into smaller rooms.
In the interwar period a new concept of hospital construction was being born: blocks, often many stories high were developed, with the idea of improving communication and circulation of patients and staff between wards and diagnostic facilities. Block hospitals were popular across Europe and in the United States until the 1970s, and as they grew larger access to fresh air, light, and contact with nature was reduced. The Hôpital Bichat, in the north of Paris, has a high rise glass and concrete block completed at the end of the 1970s, springing out of the old low rise pavilions and bringing the number of beds on the site to over 1,000. The development of medical technology and subspecialization encouraged larger hospitals, but these supersized establishments were found to be less successful that had been hoped. From the 1980s, smaller hospitals of around 500 beds were built and their construction placed in the hands of specialised healthcare architects, capable of designing patient friendly buildings that would adapt to the changing requirements of health care.
As a result of centuries of piecemeal evolution, hospitals in Paris display an anarchic mixture of styles, with stone chapels and covered galleries, brick pavilions from the early 20th century, and concrete blocks from the 1960s, all rubbing shoulders with the latest glass and steel towers. In the shade of the new buildings, hospital gardens still survive with green lawns, neglected fountains and pollarded limes, laid out in the uncompromising symmetry beloved of French gardeners.
Walking around a French hospital is a rewarding experience. It is not only possible to guess the age and purpose of the various buildings, but a rapid look at the hospital plan serves as an introduction to the history of medicine, particularly at a specific site. The French revere the great (French) men of medicine, and buildings are named after locally or nationally celebrated physicians, politicians, and philanthropists. I notice, sadly, that famous women are rarely mentioned, with the exception of Marie Curie. All the separate buildings in my hospital are named, and each building has a plaque with a picture and brief biography of the physician concerned. This naming persists to the present day: the 450 bed building currently under construction on the site of the Hôpital Necker in central Paris will be named after René Laennec, the inventor of the stethoscope, who was appointed to the hospital staff in 1816.
The central role of hospitals is to care for the sick, and while concepts of hospital architecture may have changed over the years following the tenets of medical teaching the buildings have always been dedicated to healing. Built to impress, built according to a particular architectural style or simply following function, hospital buildings can be seen evolving over time, some more successfully than others. Bringing some of the older French hospital buildings up to modern standards of care is uneconomic and so they have been transformed into office space: the rebuilt Hôtel-Dieu in Paris will probably in the end become the administrative seat of the Parisian health service. Others are in continued use: one of the wings adjacent to the chapel in my hospital, built in the mid 19th century, still houses the pediatric service, although it is unlikely that the original architects would recognise the interior. Hospitals should perhaps be seen as organic: evolving over time to meet the demands of technology and patient expectation, expanding and contracting, and bearing the traces of their previous incarnations to be admired by the curious.
DR. SARAH HARTLEY is an English sleep physician working in a French public hospital. She did her preclinical training at Gonville & Caius College, Cambridge. Before the development of Addenbrookes hospital as a clinical training hospital, Cambridge scattered its graduates to Oxford and to the London hospitals. She completed her clinical training at Green College in Oxford. After house jobs she became an intern at the hospital Tenon in Paris, where she worked for 18 months and was fascinated by the differences between French and English health beliefs, prescribing practices, and training. On her return to the UK she trained as a general practitioner and in 1995 was appointed to the faculty of the Imperial College. She moved back to Paris is 2001, trained as a sleep physician, and has been on the staff of the Hôpital Poincaré ever since.