What a fascinating book!

Yanni is an architect who has written this book about the architecture of hospitals for the mentally ill.  It is a topic which was widely treated in the psychiatric literature of the nineteenth century but which is more quiescent now. 

She basically discusses four topics in the 160 pages of text, starting with a consideration of the linkage between moral treatment, a major theme in the psychiatry of the late eighteenth and entire nineteenth century, and the architecture required to conduct it.  Pinel, the founder of moral treatment, asserted that insanity was treatable and that the mentally ill should be able to walk the beautiful grounds of the Salpetriere.  Tuke, in England, had good results with such a model.  She then considers the influence of  Dr. Thomas Kirkbride, who had very specific ideas about the structure of asylums — ideas which were greatly respected and implemented throughout the United States and to some extent in Europe.  Hospitals based on these models had beautiful grounds and a structure of pavilions, connected to each other and arranged in a "V" shape.  Kirkbride believed that 90% of the mentally ill were curable.  Soon, however, Tuke's model of 30 patients in an asylum was converted to 600 patients, and then more — often thousands, which placed a strain on both the treatment and the architecture!.  Yanni then considers an opposing plan which developed a bit later, the "cottage" plan, in which there were multiple, smaller buildings.  Butler and Olmsted were advocates of this approach.  Finally she considers various architectural styles of hospitals which developed after the Civil War, ranging from the "hospital architecture" style of Johns Hopkins to styles which appeared like colleges, to a rather motley array of buildings adapted for use as hospitals for the mentally ill.  In the era of miasma theory, there was much discussion of cross-ventilation as a desideratum.  She concludes with four fascinating appendices on terminology, the occupations of patients in 1850, the construction costs of many of the hospitals, and the sizes of these hospitals between 1770 and 1872.

The author examines the relationship between architecture and treatment in psychiatric hospitals over several centuries.  There was a deep-seated belief that treatment should be provided in home-like surroundings, though many of the patients had lived in far worse conditions at "home" than in these hospitals.  Though many of the buildings were of great beauty, there were problems and criticisms.  The nineteenth-century neurologist, Edward Spitzka, for example, wrote that psychiatrists were interested in "tin roofing, (although the roof and cupola are usually leaky), drainpipe laying (although the grounds are often moist and unhealthy), engineering (though the wards are either too hot or too cold) … experts at everything except the diagnosis, pathology, and treatment of insanity."   And Nellie Bly, the nineteenth century reporter, wrote of Blackwell's Island Asylum:  "I looked at the pretty lawn, which I had once thought was such a comfort to the poor creatures confined on the island, and laughed at my own notions.  What enjoyment is it to them?  They are not allowed on the grass — it is only to look at."  There is a great deal of old commentary of this nature, and the author has done well to find it and to excerpt relevant statements.

This is a beautiful book, with some wonderful photographs and illustrations.  The author has some interesting comparisons:  for example, nineteenth-century prisons differed architecturally from nineteenth-century asylums based on the capacity to keep prisoners in view, which was much greater than that for psychiatric patients.  Cells at Auburn State Prison were 7 feet by 3 feet, while asylum rooms were generally 9 feet by 12 feet.  She wanders into some territory not strictly defined by architecture, such as the frequency of "lunatic balls" in some of the hospitals, and this is truly fascinating material.  She writes of the resemblance of some of the hospitals to nineteenth century colleges and adds, "Colleges and asylums transformed the minds of their residents."  Similar epigrams pop up throughout the book.  She discerns an extremely important point as she writes of early efforts to treat the mentally ill in the community rather than in hospitals, and what she describes has happened again in recent decades:  "… An insidious result ensued:  the psychiatric profession gradually turned its attention away from the poorest, sickest patients… The budding field of psychiatry in the 1840's … once zealously attended to friendless and hopeless lunatics".

The author is not a psychiatrist or historian of psychiatry, and she is sometimes a bit naïve about historical clinical issues, but these lapses are few, and for the most part she has educated herself very well about the history of psychiatry.  There are few negative aspects of the book.  Occasionally, because of the inherent architectural interest of some of the buildings, she digresses, as she does with accounts of the Utica Asylum and the Willard Hospital for Incurables.  Neither of these hospitals fit the architectural paradigms she is discussing, but they were interesting buildings and unique hospitals.  I do disagree with one statement of hers:  "As the medical hospital increased in eminence, the asylum declined… State mental hospitals had lost status, drifting away from science and appearing to physicians as mere warehouses for humans:  little or no research was conducted there."  Certainly this was the case for many of the asylums, but in the era of  psychoanalysis in the university medical centers, a few state hospitals were doing essentially all of the biological research in psychiatry, and some of it was very good research.

I resonated to this book in part because of my interest in the Rochester State Hospital, which opened in 1879.  Like many of the great hospitals discussed in the book, it met a sad fate, being transformed into a federal prison hospital.  In its heyday it had beautiful grounds, all kinds of programs for the patients, including a traveling glee club, fine psychiatrists and good treatment, and, later, some very good research.  Built as a hospital for 200 patients, it accommodated thousands, at times.  There was a lot more to this hospital than the architecture, but the architecture was important.

Yanni concludes, "With some trepidation, I present a viewpoint at the end of this book that undermines one of the central ideas that launched me on this project:  that architecture is important to the care of the mentally ill.  I have noticed in my historical research and in conversations with doctors and patients that the staff of a mental health facility is crucial to its success."  I agree with her completely about the primacy of the competence and commitment of the staff, but she is a bit unfair to her profession:  great  architecture is helpful if not essential.

I enjoyed Yanni's book and highly recommend it to psychiatrists and those interested in psychiatry.

© 2007 Lloyd A. Wells

Lloyd A. Wells, Ph.D., M.D., Mayo Clinic, Department of Psychiatry and Psychology, Rochester, MN 

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