In the late nineteenth century, the American system of medical education underwent a complete transformation. Medical colleges shifted from commercial schools where instruction was based almost exclusively on classroom lectures to university-affiliated programs providing hands-on training in both laboratory and clinical work. Medical educators recognized that successfully enacting the new pedagogy required new buildings. By the 1930s, almost every medical college in the United States had rebuilt or significantly renovated its facilities. In Creating the Modern Physician: The Architecture of American Medical Schools in the Era of Medical Education Reform, Katherine L. Carroll analyzes the first wave of schools constructed to house the new medical training. She examines the three dominant types of American medical school buildings, which she argues did more than supply spaces for teaching and research—they defined specific conceptions of modern medicine and helped to shape the modern physician.
A revolution took place in American medical education in the late nineteenth century.1 Poorly regulated, commercial schools offering repetitious lectures transformed into standardized, university-affiliated departments dedicated to experiential learning and scientific medicine. This major pedagogical shift rendered obsolete even the newest and most modern medical college buildings. In the forty years between the opening of the landmark Johns Hopkins Medical School in 1893 and the sudden decrease in medical school construction brought on by the financial collapse of the 1930s, medical colleges across the country rebuilt or substantially renovated their facilities (Figure 1).
Medical educators recognized that a new building did more than provide the needed lecture halls and laboratories. As prominent medical educator G. Canby Robinson explained in 1923, “We have … at present a rapidly increasing number of schools in which the opportunity is afforded to construct new plants or thoroughly remodel old ones along lines which express the modern American conception of medical education.”2 Committed to creating spaces that would define medicine according to modern ideals and make possible the most progressive pedagogical aims, medical educators joined with architects, philanthropists, and state governments to construct facilities that would help place American medical training among the best in the world and that would ultimately shape American medical education to the present day.
Previous scholarship on medical architecture has focused on places for patient care, particularly hospitals, rather than on buildings for medical training. While the literature on hospitals is large, research on the architecture of medical schools is just beginning to emerge.3 My examination of the facilities at a broad cross section of medical schools in the United States between 1893 and 1940 represents the first comprehensive analysis of American medical school architecture.4 This article investigates the development of three medical school building types: the institute design; the single-building facility for preclinical studies, typically adjacent to a hospital; and the unified medical school–hospital. This is more than a typological study, however; I argue that the physical plants helped to define modern medicine. The ideas that underpinned the schools’ designs became codified and then promoted by the buildings themselves, creating a dialectical relationship between science and architecture.
American Medical Education in the Nineteenth Century
Medical historian Kenneth M. Ludmerer has described the nineteenth-century developments in American medical education. By midcentury, the typical American medical student received paltry training at best. The colonial era's apprenticeship system had largely disappeared, and the so-called proprietary school had taken its place. The faculty ran these schools, which grew significantly in number over the course of the century, primarily as commercial ventures, generating profits from student fees. Such a system encouraged large class sizes and poor educational standards. The schools offered four-month terms that students attended for two years, repeating the same classes twice. While some schools provided hands-on dissection, most included no laboratory or practical clinical work. Instead, the colleges relied almost entirely on lectures. Students earned their medical degrees by passing perfunctory oral examinations; they were not required to demonstrate their ability to read or write. Highly motivated students could pursue supplementary educational opportunities, however, either before or after completing their degrees. Some students spent time as “house pupils,” living in hospitals and gaining practical experience with patients. For those with financial means, other options included nondegree summer programs focused on clinical instruction and study in Europe.5
After the Civil War, recently graduated physicians traveling abroad often went to Germany, the international leader in scientific medicine. In addition to providing strong clinical training, Germany offered well-funded university laboratories that encouraged new research within an invigorating academic environment. Here American doctors discovered experimental methods and the basic medical sciences, such as biochemistry, physiology, and bacteriology. While most American doctors abroad spent their time improving their clinical skills and returned home to specialize in new fields such as dermatology, ophthalmology, obstetrics, and gynecology, a subgroup of Americans devoted themselves to the laboratory and the basic medical sciences. When these physicians returned to the United States, they took faculty positions at a handful of medical schools, from which they would lead the country's revolution in medical education.6
During the 1870s and 1880s, the medical schools at Harvard University, the University of Pennsylvania, and the University of Michigan instituted significant reforms. The new American system of medical education did not fully take shape, however, until the opening of Johns Hopkins Medical School in 1893. Students entering its four-year program faced rigorous admissions requirements. They then received two years of instruction in the basic medical sciences with significant laboratory training. Upon completion of this preclinical work, they underwent two years of hands-on clinical experience in the school's affiliated hospital. In addition to emphasizing strong teaching, the medical college actively promoted original research. The framework for the system of medical education still in use today had been established. As the new educational ideals took root around the United States, the number of proprietary schools began to decline.7
The comprehensive change in medical education stimulated a similarly dramatic transformation in medical school architecture. Medical colleges offering little more than lectures needed only spaces for instructors to meet their students. For example, Syracuse University's fledgling College of Physicians and Surgeons rented rooms in the city's Clinton block from 1872 to 1875.8 When Howard University opened its medical school in 1868, it had similarly makeshift arrangements. During its first year, the school shared a former dance hall with other university departments, although its dissection course was relocated to a shed behind the building after the professor's family living downstairs complained.9
Stronger schools with more financial resources, however, had long enjoyed purpose-built facilities. As early as 1816 Harvard University's medical college, for example, occupied the first building erected specifically for the school.10 Several decades later, in the 1870s, Harvard Medical School stood among the first American medical colleges to begin implementing educational reforms. In 1883, the school relocated to a new facility on Boylston Street in Boston (Figure 2). The design of the new building responded to the changes in medical education and enabled the progressive education of its occupants. The facility offered students laboratory space in five areas: anatomy, physiology, chemistry, histology, and pathology (Figure 3). These resources far eclipsed the limited accommodations for laboratory training in the school's previous home.11 Contemporary reports recognized the critical role the new building would play in the educational transformation under way at the medical school and lauded the carefully planned laboratories and lecture rooms.12 Funded by gifts totaling nearly $300,000 and erected in Boston's growing educational center around Copley Square, the five-story, Romanesque revival facility designed by Ware and Van Brunt heralded the architectural revolution that would soon sweep the nation's medical schools along with the educational reforms that the Harvard Medical School helped to promote.13
The Institute Design
In 1893, the Johns Hopkins Medical School opened in Baltimore, Maryland. At its outset, the school formulated the full articulation of the modern American system of medical education. The architectural expression of the new educational approach, however, came about in a much more piecemeal fashion.
In 1873, Johns Hopkins, a Baltimore businessman and the largest shareholder in the Baltimore and Ohio Railroad, died and left funds for the creation of a university and a hospital, both of which would bear his name. Hopkins requested that the university include a medical school and that this medical school work closely with the hospital.14 The university and the hospital, however, struggled to follow his mandates. In both cases, only the income from Hopkins's gift could be used for construction, a financial challenge compounded by a reduction in income from the university's and the hospital's respective endowments during their early years. Significant proportions of both institutions’ resources came in the form of Baltimore and Ohio Railroad stock, which produced diminishing dividends between 1886 and 1891. After having to delay its intended opening for four years, in 1889 the hospital welcomed its first patients, but the university was unable to begin offering medical training at that time.15 In the end, four more years passed before medical students arrived at Hopkins in 1893, a development famously made possible by a group of women who raised the $500,000 necessary to make the Johns Hopkins Medical School a reality. The terms of the gift, however, stipulated that not more than $50,000 of the original benefaction could be spent on buildings.16 The relative lack of funds necessitated a slow construction schedule for the medical school. The gradual expansion of space was acceptable because the school added a class a year and did not need to support four classes of medical students immediately.17
By the close of the 1898–99 academic year, the Johns Hopkins Medical School had completed its first campus. In 1893, the medical school added two floors to the existing pathology laboratory on the Johns Hopkins Hospital site. On the medical school lot diagonally behind the pathology laboratory, the medical college had subsequently constructed the Women's Fund Memorial Building (1894) and the Physiological Building (1898 or 1899) (Figures 4 and 5).18 Local architect George Archer designed all three of these new facilities.19 Reports of the Johns Hopkins Hospital's superintendent indicate that during the 1890s the hospital also augmented its buildings to accommodate medical students, specifically by adding classrooms and clinical laboratories.20
A lack of extant buildings and architectural plans limits study of this initial campus for the Johns Hopkins Medical School. The three major spaces erected for the school—the addition to the pathology laboratory, the Women's Fund Memorial Building, and the Physiological Building—have been razed, and architectural plans currently exist only for the Women's Fund Memorial Building.21 Fortunately, descriptions of the facilities remain and allow for a general understanding of their design and use. An analysis of these early buildings indicates that the leaders of the medical school returned from their studies in Germany with an appreciation not only for that country's system of scientific inquiry and experiential learning but also for its division of universities into institutes.
When the Women's Fund Memorial Building opened in 1894, instruction in physiology remained at the separate Johns Hopkins University campus, and the medical college's leadership recognized that the new building did not fully provide for the needs of the medical school. The medical educators and architect conceived of the Women's Fund Memorial Building as the first step in the construction of a complete medical school campus. Historical documents contain references to more comprehensive visions for the medical school site that express a desire to create a square composed of a prominent building at the front of the lot, for the administration or the museum and library, flanked by a series of ancillary buildings, each devoted to a specific laboratory subject or two.22 A pre-1916 drawing of the Johns Hopkins Medical School campus shows the ultimate placement of the Physiological Building and the Women's Fund Memorial Building (labeled Anatomical Laboratory) on either side of a projected quadrangle (Figure 6).23 The location of these structures significantly away from Monument Street left room for an administration building to be erected in front of them. As often happens, however, later construction did not follow the original aim. In 1905, the first Hunterian Laboratory was built between and behind the earlier two buildings, and in 1916, the second Hunterian Laboratory was completed on the corner of the site behind the Women's Fund Memorial Building (see Figure 4). In 1929, the school erected the Welch Medical Library in the space along Monument Street that had been reserved for the campus's main building.
In the abstract, the leadership at Hopkins could have planned to expand the Women's Fund Memorial Building as more funds became available rather than construct separate structures. In the end, however, they envisioned a campus composed of a series of laboratory buildings dedicated to discrete subjects, drawing on the German institute design familiar to men such as William Osler and William Welch, both of whom had studied in Germany and helped found the medical school at Hopkins.24 In Germany, American medical men became familiar with universities made up of many institutes, each of which focused on a particular discipline. A separate physical and administrative unit within the university, an institute typically enjoyed its own facilities; housed expensive equipment, including scientific devices and extensive libraries; contained a large staff; and benefited from a generous budget.25 A published site plan of the University of Kiel from 1890 depicts the German university's physical division into institutes (Figure 7).
In the nineteenth century German universities developed into centers for original research, and with this change, institutes increased in number in both philosophical and medical faculties.26 Between 1860 and 1914, at least 173 institutes were founded in the medical faculties of German universities. Frequently, these institutes supported new fields of study, such as hygiene or otolaryngology. At the same time, however, huge sums of money went to established institutes, such as those devoted to anatomy or surgery, to erect new buildings and improve working conditions.27 German universities were the primary creators of the institute model, but it migrated to universities that drew on the German system, particularly in Scandinavia, Russia, Eastern Europe, Switzerland, and the Netherlands, and inspired significant change in university research and teaching in the United States.28 It is widely recognized that the German commitment to scientific inquiry had a lasting impact on American medical education. In this article I will argue that the American men who trained in Germany's laboratories also brought that country's architectural ideas back to the United States.
While a lack of finances forced Johns Hopkins Medical School to construct a modified version of its intended institute design, Harvard Medical School suffered from no such monetary constraints. With substantial support from a handful of private donors, in 1906 Harvard Medical School moved from its building on Boylston Street to an entirely new campus in the Longwood area of Boston.29 Shepley, Rutan, and Coolidge, an architectural firm with a well-established relationship with Harvard University, designed the five-building complex, which was constructed for the staggering sum of more than $2.6 million, nearly twenty times the combined cost of the Women's Fund Memorial Building and the Physiological Building at Hopkins (Figure 8).30 The buildings of the classical revival marble quadrangle were not only aesthetically grand but also large. Each provided as much space as the medical school's entire previous home on Boylston Street.31 The buildings also created the formally organized, comprehensive plant that had eluded the medical educators at Johns Hopkins.
In line with German institute design, separate structures divided the campus by academic discipline. While the building at the head of the courtyard held primarily the administration and the museum, each of the other structures provided space for two departments. The wings of these U-shaped buildings housed the laboratories, with libraries and lecture halls in the connecting sections (Figure 9).32
Unlike at Hopkins, where the leadership never explicitly mentioned the German institute model, Harvard acknowledged the roots of the design in a medical school publication:
To Professor H. P. Bowditch belongs the credit … in association with Professor J. C. Warren, of devising a scheme along the broad lines on which the plans of the new School have been worked out. He proposed a group of buildings arranged somewhat on the plan of the modern German medical school—that the various departments should be housed in separate “Institutes”—such as the Institute of Anatomy, the Institute of Physiology.33
Both Bowditch and Warren had studied in Germany, but Bowditch's experience in particular deserves special consideration. While the Harvard publication claimed only a general link to German institute design, Bowditch's correspondence suggests that the footprint and interior arrangement of the Harvard buildings may also have drawn on the German model.
In 1870, when Bowditch was working in the recently opened Physiological Institute at the University of Leipzig under the direction of renowned physiologist Carl Ludwig, he wrote to the Boston Medical and Surgical Journal to describe his experience. He explained to readers that few Americans traveled to Leipzig, as they preferred instead the larger cities, such as Berlin and Vienna, with better clinical opportunities. For fledgling chemists and physiologists, however, Bowditch promised that Leipzig offered the best resources in all of Germany.34 Indeed, when Ludwig joined the medical faculty at the University of Leipzig in 1865, he created a physiology institute that influenced many future doctors and universities in addition to Bowditch and Harvard. Ludwig's institute not only made a number of major discoveries, but it also became the preeminent location for investigation and training in physiology.35 In 1869, Ludwig's institute moved into a new building. In the two decades after 1870, eleven similar institutes erected at other German-speaking universities followed Ludwig's institute model.36 In his letter, Bowditch took care to describe the new building in detail and asserted that “it is universally acknowledged to be the most complete establishment of the kind in Europe.”37
The Longwood laboratories at Harvard that Bowditch would later help to plan included several basic components found at Ludwig's institute. The Physiological Institute in Leipzig had a U-shaped plan with a lecture hall projecting from the rear of the central portion of the first floor (Figure 10). As in the Boston buildings, the wings and connecting corridor of the German institute's first floor contained various types of laboratory space in addition to storage and a small library.38
The U-shaped design that appeared on both sides of the Atlantic seems to have served two functions. First, laboratories required ample light. A plan composed of relatively narrow wings ensured that interior spaces did not lack for natural illumination (Figure 11).39 Similarly, the U shape allowed for uniform ventilation, another consideration for some laboratories. Second, large communal spaces, such as the library and lecture hall, could be accommodated in the central portion of the building. This location made these rooms easily accessible and divided the building into zones. The central area was most public, with all faculty and students mingling to use the library and auditorium. The wings offered more privacy as professors and students retreated to their respective laboratories segregated by discipline, research project, or course.
More than thirty years would pass between the publication of Bowditch's letter and the erection of the Longwood plant, but the Harvard facilities were still considered very much of their time. Harvard Medical School faculty member J. Collins Warren, who, like Bowditch, was instrumental in the construction of the 1906 facilities, wrote that “a plant of … a series of buildings for the School [was] similar in general plan to those which Dr. Bowditch pointed out existed in some of the most recently organized of the German medical schools.”40 More than a building form familiar to the Harvard Medical School leadership, the U-shaped institute design represented a plan that had proven successful for physicians in the world's leading medical nation.
It is difficult to determine if the U-shaped design was common in Germany. No German- or English-language scholarship provides a comprehensive overview of the architecture of German medical institutes, although the plans of a number of German institutes have been published.41 These plans indicate that Ludwig's Physiological Institute was not the only institute with a central lecture hall. For example, the first floor of the University of Berlin's Anatomical Institute, built in 1865, contained a central auditorium with laboratory and collection spaces in the wings.42 Ludwig's institute, however, appears to have been the direct point of contact between this basic plan and the faculty of the medical school at Harvard.43
While students at Harvard might not have realized the German roots of their medical school, the design had a tremendous impact on their daily academic lives. The institute plan reinforced the curriculum inaugurated during the 1899–1900 school year. Most significantly, Harvard compressed the instruction in each of the main preclinical subjects into one semester of the first or second year. This so-called concentrated or block system required that each subject be taught for more hours each day over a shorter number of months. For example, rather than balancing anatomy, histology, physiology, and physiological chemistry during the entire academic year, a student learned only anatomy and histology from October through January of the first year and then physiology and physiological chemistry in the second half of the year.44 As Harvard Medical School faculty member W. T. Councilman explained, the new curriculum provided a carefully crafted intellectual journey for the student:
Form and structure come first in the study of objects, so in the first term in the School the time is spent on the study of anatomy. The second term is devoted to physiology or the study of function.
In the first term of the second year the student takes up pathology, in which the disorders of form and function are considered. In the second term of the second year he learns and practises the methods which are used in clinical work. This is a natural transition of subjects, and the student goes to clinical work feeling that there is no violent break of connection, but that it is merely a continuation of the kind of work he has been doing.45
Councilman wrote this analysis in 1907, a year after the new buildings opened. An examination of the buildings indicates that they reinforced and promoted the pedagogical experience. The laboratory buildings paired the same subjects that were grouped in the new curriculum.46 For example, anatomy and histology occupied the student during the first semester of study, and Building B housed both (see Figure 9). Inside the building, the two departments shared the central lecture hall and library. The use of the latter, in particular, would have brought faculty from both disciplines in contact with each other, encouraging and reinforcing the transfer of ideas between the departments. Pedagogy and architecture together signified to students and faculty that these disciplines were closely related within modern medicine.
The new buildings carried the relationship between pedagogy and architecture a step further. As students advanced through the curriculum, they moved through the buildings progressively.47 For the first term of their first year, students learned anatomy and histology in Building B, where they spent their entire academic day, with the possible exception of excursions to the administration building (see Figure 9). They studied physiology and physiological chemistry in the second half of the year, when they moved to Building C. Their second year began with courses in bacteriology and pathology in Building D. In the second half of the second year, students did not follow a block schedule, instead balancing the remainder of the preclinical work with the beginning of their clinical training. A portion of their time, however, was spent in Building E, where they learned pharmacology and hygiene and completed their trek around the medical school's quadrangle.48 The Harvard quadrangle actively contributed to defining modern medicine and training modern physicians.
The conceptual and physical relationships established by the quadrangle also encouraged efficient movement of students and faculty. If the most closely aligned disciplines shared the same building, collaborating faculty had only short distances to travel to interact with one another. In addition, concentrating students’ courses within a single building reduced their movement around the quadrangle over the course of the day. Moreover, as Harvard Medical School faculty member and dean Henry A. Christian explained, the block schedule itself minimized students’ daily travel time: rather than moving between several rooms during the day, they spent the morning in one laboratory and the afternoon in another.49
A Progressive Era obsession that permeated American society, efficiency remained a concern for medical educators and architects of medical schools throughout this period. The consolidation of the Johns Hopkins Medical School on one campus and its location near the hospital served to reduce the movement of students and faculty and to increase their efficiency. Once reformers of medical education affirmed the need for hands-on clinical training, medical schools and hospitals frequently located near to one another, sometimes with corridors or tunnels connecting the facilities.50 The Harvard leadership worked to ensure that a hospital soon joined its medical school in Longwood, and the Peter Bent Brigham Hospital opened in 1913 directly behind the medical school campus.
Even before the groundbreaking for Harvard's new buildings, however, one faculty member recognized the plant's relative lack of efficiency and reflected on the extraordinary cost of the campus. Writing to Harvard president Charles Eliot, Charles Minot lamented that the school wasted space by planning four laboratory buildings rather than two. He asserted that two buildings would prove more convenient for the occupants and save $200,000.51 Others likely shared such concerns, for the institute design failed to become the predominant plan for medical schools in the United States. Only a few medical colleges, such as those at Washington University in St. Louis in 1914 and Emory University in 1917, constructed facilities composed of multiple laboratory buildings. Instead, most American medical schools chose one of two single-building designs that were more economical, improved efficiency, and supported alternate conceptions of medical science, generating a different paradigm for medical education.
The Single Building for Preclinical Studies
In the early twentieth century, the overwhelming majority of American medical colleges employed single buildings for the preclinical studies covered during the first two years of medical school. Medical colleges chose the single building for preclinical sciences approximately twice as often as they selected an institute design or a medical school–hospital (discussed below).52 Schools with purpose-built facilities had long utilized the single building for preclinical work. For example, all three of the previous buildings (completed 1816, 1847, and 1883) that housed the Harvard Medical School before it opened its 1906 quadrangle followed this type. During the reform movement, both prominent medical colleges, such as the one at Western Reserve University in 1924, and struggling medical schools, such as the one at Howard University in 1927, created single buildings for preclinical studies. Syracuse University College of Medicine represents a typical medical school; it provides an example of this most common medical school type and illustrates the challenge faced by many schools of meeting the financial demands of medical education reform.
In 1910, the so-called Flexner Report scrutinized medical training in the United States and Canada.53 The Council on Medical Education of the American Medical Association initiated the study as a means of encouraging the ongoing reform of medical education. Funded and published by the Carnegie Foundation for the Advancement of Teaching and authored by American educator Abraham Flexner, the report functioned in two ways. First, it described and celebrated the system of medical education recently created at elite, university-affiliated American medical schools. Second, it enumerated unflinchingly the deficits and assets of each American and Canadian medical college. Ultimately, the report codified the reform movement already in progress and accelerated the transformation of medical education across the country.54
Unlike many schools, Syracuse University College of Medicine fared relatively well in the report. Flexner gave the school's laboratory offerings a positive review, reserving criticism for the clinical portion of its medical training. When comparing New York State medical schools, Flexner lauded Syracuse for its university affiliation and its financial practices. Not only did the medical college use all of the profits generated from student fees for improving the school rather than padding the professors’ pockets, but it also attracted outside gifts. For these reasons, Flexner asserted that of the New York State medical schools not located in New York City, only Syracuse might survive the period of medical reform.55 Flexner did not anticipate the trouble Syracuse University would subsequently have raising money for its medical college, however.56
While faculty, alumni, and the university had raised $40,000 toward the medical school's well-equipped 1896 building, in succeeding decades outside support on the scale necessary for a more modern medical school did not materialize.57 Adjacent to Syracuse University a constellation of clinical facilities made the first steps toward a medical center, but the medical college remained across town in its increasingly antiquated and overcrowded building.58 By 1935, the Syracuse medical school praised in the Flexner Report faced the possibility of losing its Class A rating from the American Medical Association due to its poor facilities. Fortunately, the New Deal offered the university the financial means to build its long-anticipated new medical college. The university received a loan for $825,000 from the Public Works Administration to construct the new edifice.59 Designed by Dwight James Baum and John Russell Pope, an architectural partnership with an established relationship with Syracuse University, the relatively modest building for preclinical studies finally moved the medical college to the site of the university and the growing medical center in 1937 (Figures 12 and 13).60
With clinical training occurring in nearby hospitals, the new medical school building provided all of the facilities for the first two years of medical education under one roof.61 Although housed in one structure rather than five, Syracuse's new medical college incorporated many of the same ideas that had shaped Harvard's quadrangle thirty years earlier. First, like the Harvard laboratory buildings, Syracuse's new college formed a U shape, with an auditorium along the back of the central section on the first floor (see Figure 13). Second, like most medical schools around the country, Syracuse University's school had adopted the block plan for the schedule of the first and second years.62 A university publication devoted to the medical school explained the first two years of the program: “In these courses the various subjects are correlated, so that the relation of each subject to the others and of all to the purpose of grounding the student in the sciences essential to the practice of medicine, is ever kept in view.”63 Although Harvard would likely have described its curriculum similarly, each school chose to align the preclinical subjects somewhat differently, a fact that highlights the ways local understandings of modern science influenced both pedagogy and architecture.
Despite the varied organization of the two schools’ preclinical disciplines, Syracuse followed Harvard in physically coordinating the departments linked in the curriculum. The north corridor of Syracuse's U-shaped facility accommodated anatomy in the basement, histology (and presumably embryology) on the first floor, anatomy on the second floor, and physiological chemistry on the third floor. During the first semester of the first year, students learned anatomy concurrently with histology and embryology; during the second semester of the first year, they studied anatomy, neuroanatomy, and physiological chemistry. As a result, they spent their entire first year in the north wing. The south corridor contained bacteriology and physiology on the second and third floors, respectively. These subjects occupied students during the first semester of the second year, during which time they also began their clinical training. In addition to pharmacology and more clinical training, the next semester emphasized pathology and clinical pathology, both of which were housed along the central corridor of the second floor.64 As at Harvard, courses that the college understood as representing conceptually related disciplines were located adjacent to one another in the curriculum and in the architecture, reducing the intellectual and physical distance between the subjects.
Syracuse's compact medical school provided laboratories, rooms for research, and library facilities, as well as museum, administration, and extracurricular spaces. Medical colleges such as Syracuse that arranged their entire schools in single buildings promoted greater levels of coordination among all departments than did those with institute designs. Even if the anatomists dissecting in the north corridor of the basement rarely ventured to the Bacteriology Department in the south corridor of the second floor, all professors entered the Syracuse facility through the same doorways, moved through the same hallways, and reviewed journals together in the school's library (Figure 14). Unlike the institute design, this efficient plant encouraged the integration of the various departments celebrated by medical educators at the time.65
As medical schools considered whether to construct institute designs or single buildings for preclinical studies, the leaders of the medical colleges weighed many factors. Beyond ideas of efficiency and departmental coordination, they discussed the lower cost of a single building, as well as their conceptualizations of modern medicine.66 Wilburt C. Davison, the dean of Duke University Medical School during its construction in the late 1920s, explained the philosophical differences between an institute design and a plan that consolidated the medical school under one roof. He asserted that those who supported a unified design wanted their students to understand the branches of medicine as parts of a whole rather than as discrete disciplines.67 A different understanding of medical science represented one component of the decision to create a single-building plant.
Finally, the vagaries of local history also affected the choice of building type. At Syracuse, hospitals arrived first in the area of the new medical center. When it came time for the school to move, there was no need to construct a new hospital simultaneously. Other localities, however, built new medical schools and hospitals at the same time. During the 1920s and 1930s, the opportunity to construct a medical school and hospital concurrently resulted in a new design that replaced the institute plan as the most progressive medical school type in the United States. The new building type coordinated medical school and hospital into one structure, taking the idea of unified medicine and consolidated buildings in a direction at once both very familiar and fundamentally different.
The Medical School–Hospital
In the early 1920s, a model collaboration took place at Vanderbilt University. G. Canby Robinson, the determined and innovative dean of Vanderbilt's medical school, joined forces with Shepley, Rutan, and Coolidge (known by this time as Coolidge and Shattuck), the premier architectural firm of American medical schools, and the General Education Board, the nation's leading philanthropic organization committed to medical education.68 Together they imagined, designed, and funded the country's first medical school–hospital, which opened in 1925 (see Figure 1).69
Early plans for Vanderbilt's new medical school depict a conventional facility. On the South Campus, 2.5 miles by automobile from the main university campus, three buildings housed the school of medicine. Two buildings contained preclinical departments, and one accommodated laboratories for anatomy, histology, and pathology on the top floors, with the school's hospital and dispensary on the lower two floors.70 Two unsigned sketches made in fall 1919 and spring 1920 reveal the intention to keep the medical college on the South Campus and to construct a relatively typical single building for preclinical studies near the existing Galloway Memorial Hospital, with a corridor connecting the medical school with a proposed hospital extension in the later sketch (Figure 15).71 By the summer of 1920, however, Coolidge and Shattuck had drawn a plot plan for a medical campus with an entirely new design: a series of hospital buildings attached directly—with no intervening corridor—to one wing of a medical school that wrapped around an open courtyard (Figure 16).72 In its fledgling form, the unified medical school–hospital was born.
To enact this new vision for a combined medical school–hospital, however, Robinson needed funding. In September 1920, he sent a proposal to Vanderbilt chancellor James H. Kirkland and the General Education Board, where Abraham Flexner now ran the medical education program. Robinson called for a complete redesign of the Vanderbilt University School of Medicine—conceptually, pedagogically, and architecturally. Early in his report, he made a bold statement:
A guiding principle which I believe is to be an important factor in advancing medicine and medical education is coordination of departments, and this conception has been kept in mind in the planning of buildings and in the organization of departments. Although much has been accomplished by the German “Institute” method, in which each department is a defined entity, often physically removed from the other departments, much more may be accomplished by a medical school which forms one “Institute,” grouped about and participating in the study of disease, especially the study of disease in living human beings. No medical school has yet been developed with this as a fundamental conception, and the time is now at hand for the establishment of such a school.73
Robinson imagined a medical school that would function as a single institute, including not only the various preclinical disciplines but also clinical training, what Robinson referred to as “the study of disease in living human beings.”74 To make his idea a reality, Robinson suggested the physical coordination of the preclinical laboratories with the clinical work, as well as a new continuity of staff. In his scheme, the head of a preclinical department would oversee all of the research undertaken in that department's area no matter whether that work developed in the preclinical or clinical section of the school. This new physical and administrative organization would make possible a new medical curriculum much anticipated by medical reformers. In Robinson's view, the new teaching system would “allow the integration of laboratory and clinical studies which will be mutually beneficial, and which will tend to mold a new type of medical practitioner.”75
While the single building for preclinical studies, as at Syracuse, encouraged the coordination of the various laboratory subjects, the medical school–hospital focused on the unification of preclinical and clinical teaching and research. Certainly this was not a new idea. The importance of aligning the two phases of medical education had caused reformers to place medical schools and hospitals in close proximity for decades, as the early examples of Hopkins and Harvard indicate. The innovation of Vanderbilt's medical school–hospital came from its emphasis on this aspect of medical education, a shift that Robinson believed would create a new type of physician.
The idea resonated with major funding institutions. In spring 1921, the General Education Board augmented a previous gift to Vanderbilt's medical college, bringing its total support to $5.5 million, and the Carnegie Corporation gave $1.5 million. Together with an earlier $1 million gift from Andrew Carnegie, these funds provided the money needed to erect a completely new plant on Vanderbilt's main campus that enacted Robinson's vision.76 In the end, construction of the entire complex—comprising medical school–hospital, adjacent nurses’ home, and nearby combination power plant and laundry—cost approximately $3.35 million, with the remainder of the gifts reserved for endowment.77
Between making his proposal in fall 1920 and receiving the funds in spring 1921, Robinson collaborated on additional architectural plans with Coolidge and Shattuck, Kirkland, and hospital consultant Winford Smith. A sketch by Coolidge and Shattuck from the winter of 1921 shows a design for the main university campus that pushed the medical school–hospital concept even further (Figure 17).78 Rather than a medical school and hospital simply abutting one another, continuous axial corridors unified the two buildings. Whether this axial format originated with the architects or Robinson cannot be determined from the historical record. In June 1921 Robinson expanded on this idea when he created a number of sketches for the new campus that presaged its final form (Figure 18).79 In this plan, medical school and hospital became a fully coordinated facility, with a series of axial corridors aligning the laboratories directly with the wards. Robinson found a way to execute physically his conception of medical education.
Although growing out of established trends in medical education and medical school architecture, the building provided a completely new educational environment. Robinson explained his ideas in a number of publications, including an article in the prestigious Journal of the American Medical Association. Robinson used this prominent platform both to generalize about the direct relationship between the design of a medical school and the type of pedagogy it facilitated and to detail the new complex at Vanderbilt and the innovations it made possible in medical education.80 The Vanderbilt medical school–hospital aligned the preclinical and clinical departments more closely than they had been coordinated at any previous medical college. Laboratories for the preclinical sciences composed three sides of a court oriented toward the north and the main Vanderbilt campus, while the hospital was grouped at the other end of the building, separated from the campus and opening onto Hillsboro Road, where it was accessible to the public by streetcar line (Figure 19). The clinical laboratories stood between the two sections, with each clinical laboratory adjacent to the preclinical subject with which it was most closely related conceptually. On the main north–south axes of the second floor, the suites of rooms dedicated to the preclinical disciplines of pharmacology and anatomy led to the related disciplines of clinical chemistry and experimental surgery, respectively, and then to the wards (Figure 20). On the third floor, one could move directly from the wings that housed preclinical physiology and bacteriology to clinical physiology and bacteriology, respectively, and then to the wards (Figure 21). Robinson hoped that this design would encourage the closest possible coordination among the preclinical departments, the clinical laboratories, and the hospital and result in the continuous transfer of ideas between the preclinical laboratory and the bedside.81
While Robinson focused on the alignment of preclinical and clinical disciplines, the facility's design also promoted other ideas important to medical educators. If merging several separate institutes into a single building for the preclinical departments, as at Syracuse, allied the medical sciences in the face of specialization, then the combined medical school–hospital at Vanderbilt extended this objective. The constant contact between the various preclinical and clinical departments made it impossible for faculty and students to ignore the interconnectedness of the disciplines. As noted earlier, Wilburt C. Davison, dean of the Duke University Medical School, wrote of the conceptual significance of a unified design in presenting medicine as an integrated whole rather than as a series of discrete parts. This idea applied to the single building for preclinical subjects, such as at Syracuse, but Davison directly referenced the medical school–hospital in comparison to the institute form.82 Robinson expanded on this point when he asserted that Vanderbilt renounced the departmental separation emphasized by the institute design in favor of “collaboration and close contact [that] would tend to carry the school forward as a whole, without isolated departments.”83 The medical school–hospital presented the various components of the human body as an indivisible network instead of highlighting their distinctiveness. The architecture played a critical role in formulating and disseminating this understanding of modern science.
Efficiency, another familiar refrain among medical educators and architects, played a major role in the medical school–hospital. While the single building for preclinical studies increased efficiency over the institute design, Vanderbilt's combined medical school–hospital economized movement even more. In just a few steps, students and faculty could go from the laboratory to the bedside and from the library to the dining room. The relatively small size of the entire Vanderbilt facility further reinforced the ease with which faculty and students could travel from one area to another.84 Although Vanderbilt adopted the block schedule before the school occupied the new plant, it did not arrange the preclinical departments in the new building according to the alignment and sequence of the courses in the curriculum.85 As a result, students did not move through the plant in conjunction with the evolution of their preclinical classes as did students at Harvard and Syracuse. The compact nature of the plant might not have warranted further consolidation of the interior of the building, or the goal of efficient movement from preclinical department to related clinical discipline may have trumped coordinating the affiliated preclinical fields.
In the end, the medical school–hospital became the new gold standard in medical school architecture. In less than a decade, seven additional medical school–hospitals were built in the United States before the Great Depression essentially halted medical school construction. The medical school–hospitals created at the University of Colorado (1924), University of Rochester (1925), Columbia-Presbyterian Medical Center (1928), Duke University (1930), Woman's Medical College of Pennsylvania (1930), Meharry Medical College (1931), and New York Hospital–Cornell Medical College (1932) prove the adaptability of the type.86 It accommodated, for example, the broad horizontal plan at Vanderbilt as well as the tall vertical design of Columbia-Presbyterian Medical Center (Figure 22). Similarly, the medical school–hospital could be expanded to include enormous square footage, seen in the Columbia-Presbyterian Medical Center, or condensed into very economical plants such as the facility at Woman's Medical College of Pennsylvania. The design also appealed to schools in a variety of geographic settings.
The development of modern American medicine could not have taken place without the complete reform of the American system of medical education and the total redesign of the American medical school. Those involved in creating the new facilities—educators, architects, and financial donors—recognized the architectural environment's direct impact on the medical school's educational mission. Writing in 1923, just a few months before the groundbreaking for Vanderbilt's medical school–hospital, Dean Robinson explained:
Medical education is conducted in different countries in various ways…. It is not always easy to determine whether the educational principles have dominated the types and arrangements of buildings, or whether the educational principles have been dominated by the facilities in which medical education is of necessity conducted….
Only in rare instances prior to twenty-five years ago did a medical faculty [in the United States] have an opportunity to express freely any true educational policy in its plant, and in this country even today the available plant dominates the educational methods of many of our medical schools.
We have, however, at present a rapidly increasing number of schools in which the opportunity is afforded to construct new plants or thoroughly remodel old ones along lines which express the modern American conception of medical education.87
In examining the new facilities and conceptions of medical training, this article has revealed that they were hardly unidimensional; they allowed for multiple visions of modern medical education and medical science. The institute design codified and encouraged a pedagogical and scientific ideal based on classifying and separating the branches of knowledge on which medical practice was founded. In contrast, those schools that erected unified buildings—either single buildings for the preclinical departments or medical school–hospitals—endorsed an approach to modern medicine that saw the study of medicine, and by extension the human body, primarily as an indivisible whole. In the end, the medical schools did more than provide efficient space for medical instruction and research. They shaped the education formulated in their halls and nurtured a particular understanding of medicine among students, faculty, and staff.
The reform of American medical education also made it unnecessary for physicians to travel abroad to receive the best training.88 Most physicians remained in the United States, molded exclusively by this country's new pedagogical system and its buildings.89 As Robinson recognized, “The available plant dominates the educational methods of many of our medical schools.”90 With most of the buildings constructed during the reform movement still used for medical education today, the impact of these original facilities continues to be felt. The relatively swift abandonment of the institute design means that the majority of American physicians trained in the past century have been educated in one of the two unified building types and indoctrinated in the coordinated conception of modern medicine. Far from historical relics, the medical schools of the early twentieth century play an active role in creating the American physicians of today and of the foreseeable future.