8 minute read
Therapeutic landscapes
Paimio sanatorium, demonstrating the close relationship of the pine forest with the building. © Clare Hickman
A brief history of hospital gardens
On a bright, sun-filled day this summer I travelled to visit a lauded example of a historic medical institution in south Finland. A place in which the landscape was integral to both the architectural design and the therapeutic aims of the medical staff. Approached via paths woven through the surrounding pine forest, I initially glimpsed Paimio Sanatorium through the surrounding trees –its white walls bright against the dark foliage. Opened in 1933 to treat patients with tuberculosis, it was designed by the famous architecture and design duo, Alvar and Aino Aalto. For them, the location here in the pine forest was as functionally important as it was aesthetically pleasing.
The pine trees were understood at the time to have disinfecting and antiseptic properties that could affect the human body through emanations carried in the air. The design of the building and the open-air treatment approach (by which windows and doors were kept as open as possible) meant that the forest could be seen, smelt and breathed in by patients. The forest was such an integral part of the therapeutic design, it is now one of the key elements cited in the current application for Paimio to become a UNESCO World Heritage Site.
For all its modernism, Paimio’s history can be understood by viewing it within a much longer history of humans utilising plants and landscapes for health benefits. Evidence of the use of plants in healing practices can be found as far back as the Palaeolithic Age. Many centuries later, gardens were important features of medieval hospital sites across Europe, where they provided sensory places for restoration as well as the material for herbal remedies. They were also seen as spaces that could engender a spiritual sense of wellbeing and it was believed that nature, or God through nature, had provided a remedy for every ailment. In these early hospitals, God was considered to be the ‘supreme physician’.
This dual meaning provided the basis for the emergence of botanic gardens in the sixteenth century, where attempts were made to reconstruct the garden of Eden by bringing plants together from around the known world. These were also central spaces for medical education as they formed collections of plant material essential for research and the treatment of disease. It is worth noting that this is a very Western European oriented perspective and that there are also complex histories of colonialism and exploitation in relation to plant collecting and botanic gardens, as well as equally important histories of the therapeutic use and relationship to plants by indigenous people.
To return to Britain, we can trace the belief in nature and gardens as therapeutic through the design and use of asylums for the treatment of what we would now class as psychiatric disorders and related conditions. One key example of this is the York Retreat, opened in 1796, which was originally established by the Tuke family, who were Quaker tea merchants, to treat other Quakers who were suffering.
According to Samuel Tuke, at the Retreat there was an understanding of the role of both design and scale. In 1813, he wrote, “I cannot, however, forbear observing, that the courts appear to be too small, and to admit of too little variety, to invite the patient to take exercise. The boundary of his excursion is always before his eye, which must have a gloomy effect on the already depressed mind.” His argument was that this could be compensated by use of wider gardens as well as “excursions into the city or the surrounding country, and into the fields of the Institution” by those who were able. By 1847, the Commissioners in Lunacy who regulated such institutions stated in their rules for new asylums that “The airing courts, pleasure grounds, gardens and fields annexed to an asylum, should be of such an extent as to afford the patients ample means of exercise and recreation, as well as the healthful employment out of doors: and should, as far as possible, be in the ratio of at least one acre to ten patients.”
These ideas were not confined to such specialist institutions. In the 1860s, doctors John Syer Bristowe and Timothy Holmes were tasked with travelling around Britain to visit hospitals to investigate their design and how they were managed. Of the 67 hospitals they visited in England, 46 were described as having some kind of external grounds. Florence Nightingale shared similar ideas and regarded that light, as well as colour, had therapeutic benefits. In her Notes on Hospitals published in 1859 she wrote: “Among kindred effects of light I may mention, from experience, as quite perceptible in promoting recovery, the being able to see out of a window; instead of looking against a dead wall; the bright colours of flowers; the being able to read in bed by the light of a window close to the bed-head. It is generally said that the effect is upon the mind. Perhaps so; but it is no less so upon the body on that account.”
Her preferred hospital design, as stated in her book, was based around small, gardened courtyards, known as the ‘Pavilion design’. In 1854, an anonymous writer thought to be the doctor John Roberton described the Bordeaux Hospital, France, an early adopter of this plan, and how its “tiers of building are separated from each other by a flower garden, and in these tiers are the sick-wards, each ward isolated from the rest […] and in every ward when you look out of a window it is into a garden”.
In an anonymous editorial published in the same series in The Builder that year, one writer stated that “the square within the hospital, and the spaces between the pavilions, should be laid out as garden grounds with well drained and rolled walks, and shaded seats for convalescents”, which outlines how these spaces were to be used as part of the patients’ recovery programme as well as something to be seen from the windows on the wards – albeit probably not from a horizontal position in bed.
In these examples there was an embodied and sensory underpinning to the understanding of why the landscape was so essential for patients. Whether via a view through a window, the sound of birdsong through an open door, the feeling of a breeze on their face when being wheeled outside, or a walk through a garden, these institutions were designed in the belief that the external environment could play a crucial role in respite and recovery. Although it is worth reflecting that despite these intentions, oral history interviews suggest that patients did not always find this approach beneficial. In fact, their overall experience of such places could be of suffering, confinement, sometimes violence or even a pervasive sense of death, the latter of which was certainly true of the sanatorium. The aesthetic and sensory beauty of a garden is important, but a romanticised sense of these institutions should be avoided. Our medical and scientific understanding has changed significantly over time but key features such as free access to natural light and air remain important. Or at least they did until a shift in priorities in the mid-twentieth century. New medical interventions, including the use of antibiotics and developing technology, that saw the body as individual organs and cells, led to new ways of seeing the body, which was often divorced from its connection to the wider environment. Pressure on land also became more acute as hospital buildings expanded to house the new technology, and the democratisation of car ownership led to the need for vast car parks, often built over designed landscapes.
Recent years have seen a renewed interest in access to nature and the role that well designed, maintained, accessible, and cared for outdoor spaces can play. They offer places of respite for staff and visitors, as well as patients, from the noisy, sensorially overloaded hospital interior environment. Sometimes the response to this has become a technological solution, such as a piped recording of birdsong, but I am hopeful that the future will see real attempts to find ways to allow people to access spaces where they can have meaningful sensory encounters with other living beings. At a time when we are facing a biodiversity and climate crisis, there should be a renewed consideration of therapeutic spaces as places that provide care and respite for plants and animals, as well as humans.
Clare Hickman is Reader in Environmental and Medical History at Newcastle University. She is the author of Therapeutic Landscapes (Manchester University Press, 2013) and The Doctor’s Garden (Yale University Press, 2021)
