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zection of lptiemtoloov anb statefl)ebicine.President-WILLIAM BUTLER, M.B.[May 26, 1933.]

The Ventilation, Heating and Lighting of HospitalWards.By JAMES WATT, M.D.ABSTRACT.-History of ventilation in last 100 years, showingreversal of ideas andinfluence of sanatorium idea.Physiology of cool moving air. How it affects metabolism, heat-loss and heatproduction.Relation to sunlight. Reactive capacity of the individual.Practice of these teachings, as illustrated by sanatorium treatmentof tuberculosis andby open-air schools. Exposure to cooling air a powerful therapeutic

agent. Infrequentoccurrence in sanatoria of diseases or complications often ascribedto cold. Dilution ofinfection. Applicability to diseases other than tuberculosis. Shockand old age.Perflation and difusion, their relative values. Uniformity orvariability of effectdesirable ? Incompatibility of good ventilation and ordinarystandards of heating. Formerthe more important. Conclusion that ward temperatures may be loweredwithout harm.Measures necessary to compensate, clothing, classification ofpatients, small wards. Changing

standards of comfort. Psychological effects.Systems of ventilation in hospital wards. Mechanical by propulsionor extraction beingdisplaced by natural system, usually by cross-window ventilation.Supplementary ventilators.Objection to heating of incoming air. Fallibility cf human factor inmanagement.Sash versus casement windows. Hoppers. Austral window. Orientationand exposure ofwards. Ventilation of small wards. Proportion of window space tosolid wall. Balconies.Floor space.Heating of wvards. Heating of air or floor or walls. Open fires.

Value of radiant heat.Steam or water under low or high pressure. Radiators or pipes.Lighting. Avoidance of glare from windows. Arrangement of beds inwards. Colourof walls. Blinds and curtains. Artificial lighting.IT is commonly assumed that the ventilation and heating oftuberculosissanatoria are peculiar to that type of hospital and have littleapplication to general


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and fever hospitals, whose conditions are supposed to bedifferent. It is importantto try to determine whether this assumption is correct orwhether the sameprinciples, the application of which produces such strikingresults in tuberculosisinstitutions, should not also be applied in equal degree,or at least to a greaterdegree than at present, in general medical and surgicalhospitals, and in fever andother special hospitals.At the outset it is necessary to refer briefly to the recenthistory of the scienceof ventilation and the medical theories bearing on it. To do sowill at least sufficeto show how much is yet to be learned, and how little we canclaim for the finalityof our present views. It is less than a hundred years since Dr.Bodington, of SuttonColdfield, was protesting against the antiphlogistic loweringmethods of treatmentand the practice of shutting up the sick in closed rooms. Airwas then regarded asa dangerous element to be kept away from wounds. Cold air on theskin or in thelungs was particularly to be avoided by the sick. The idea-then firmly rooted thatmany illnesses were caused by a chill, survives to some extenteven now as a.cloak for our ignorance. Lister's antiseptic sprays and thegenerally held theoriesabout the conveyance of infections by the air continued toprejudice men's mindsagainst the atmosphere surrounding them. With the developmentof hygiene as ascience, there grew the idea that the air to be breathed by thesick must be filtered,warmed, and moistened, delivered to them without draught andwithout excess ofcarbon dioxide or organic emanations. Such views encouragedthe use of

mechanical systems of ventilation. Then the sanatorium idea ofthe treatment ofat least one disease in the open air began to take root inEngland half a centuryafter it was first preached. Along with this the work ofFliigge, Haldane and Hill,SEPT.-EPID. 1

Proceedings of the Royal Society of Medicine


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on the physiological action of moving air completed therevolution. Now we havereached the stage when mechanical systems of ventilatinghospitals and schools arebeing scrapped and natural cross-ventilation holds the field.Carbon dioxide, so farfrom being dreaded, is now used to stimulate respiration.Such a rapid successionof different views makes one wonder what the position will bein the course ofanother generation.The existing standards of ventilating and heating hospitalwards are determinedvery little by medical considerations, but are based on thehabits of the communitygenerally in regard to clothing and the temperature at whichliving rooms are kept.Although medical practitioners and nurses are taught a littleabout the place ofventilation in hygiene, yet relatively it is a neglectedsubject. After the architectand the builder, guided perhaps by medical advice, havesettled the form and degreeof the ventilation of a general hospital, it is seldom thatanyone takes any seriousinterest in it thereafter. In a fever hospital questions ofcross-infection anddilution of infection compel greater attention to theventilation of the wards, butit is only in tuberculosis institutions that ventilation getsconsideration as thetherapeutic agent which it undoubtedly is.Before discussing the practical aspects of the question, weought to considerwhat good ventilation is and what it does. It may be taken asproved that withinfairly wide limits the chemical purity of the atmosphere,its content of carbondioxide or oxygen or organic matter, are of much lessimportance for health thancertain physical factors which influence the loss of heat

from the human body.Life would be impossible without the faculty of sheddingheat. The three chiefways in which the body gets rid of heat are by conduction andradiation to thecolder medium surrounding it, by evaporation of moisture,visible or invisible, fromthe skin, and by warming the expired air and evaporatingmoisture from the


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respiratory membranes. Increase of heat-production withinthe body, as inmuscular exertion or in pyrexia, is followed almostimmediately by increased heatloss, and incidentally by increased consumption of food andoxygen or alternativelyby loss of body-weight. Conversely, increase of the heatloss stimulates heat production,calling for more food and oxygen, increasing appetite and theexcretoryprocesses. I may quote as an example the statement of Hill andCampbell' thatthe metabolism of children lying nude in the open air insummer at Alton was 50%above the standard figures for closed chambers, and inSwitzerland the metabolismof children lying nude and exposed to the open air was

sometimes increased over100% when there was snow on the mountains. The same authorsstate that coolconditions, e.g., sleeping out of doors, double theevaporation of water from therespiratory membranes.Much importance is now being attributed to the effect ofsunlight on health andon such diseases as tuberculosis and rickets. Patients whoare being deliberatelytreated by light, artificial or natural, have at the sametime a large area of skin

exposed to the air, and I am not sure that a large part of thebeneficial effectsobserved is not due to the latter factor. Exposure to brightsunlight withoutmovement of cool air may be the opposite of beneficial in manypersons.To obtain benefit from good ventilation a certain reactive orregulating capacityis demanded of the organism. In certain states of health,particularly in shock,this power of response is grossly defective, and in certainconditions of civilization

it is rendered sluggish through partial disuse, but it can beaffirmed that in the greatmajority of both the healthy and the sick, it is perfectlyadequate or is easilycapable of re-education. The problem of ventilation is theproblem of utilizing thispowerful exciter of metabolism within the limits of thereactive capacity of the


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individual. It does not, I presume, require arguing in thesedays that increase ofmetabolism, causing increased intake and assimilation of foodand oxygen, is theI Hill and Campbell, " Health and Environment," p. 200.

1412 7879 Section of Epidemiology and State Medicine1413best means of repairing damaged or unhealthy organs or tissuesand of securingthe elimination of the ultimate waste products and theproducts of bacterial action.This, of course, is almost the exact contrary of the "lowering" methods oftreatment by bleeding, purging, and antimony tartrate, so longin vogue.How these principles of physiology are put into practice is

best illustrated by thesanatorium treatment of tuberculosis. Here are patients of allages, suffering fromacute or chronic forms of a bacterial disease affecting chieflythe respiratory organs,but also the bones, joints, glands, kidneys and peritoneum. Ithas been wellestablished now for over thirty years that the various forms ofthis disease, no organbeing excepted, are best treated under what may be called open-air conditions,conditions where the temperature surrounding the patient is of

relatively littleimportance, so long as he is exposed to moving air, producing acooling effect. Theincreased heat-loss stimulates heat-production within the body,and increasesappetite considerably. This great principle, along with theequally important one ofrest for the diseased organ, is the basis of sanatoriumtreatment, and producesremarkable results in reducing toxaemia, improving nutritionand causing retrogressionof the disease deposits. Can methods which produce such results

in one multiformdisease not produce equally remarkable results in otherdiseases ? Are we failing toutilize in the latter a factor which would accelerate recovery? Is improvement innutrition and general health not equally desirable in thepatient recovering fromgastro-enterostomy or diabetes or diphtheria ?


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It is true that sanatorium practice in recent years has changedsomewhat in thedirection of providing greater comfort for the patient.Exposure to the open air isless drastic than it used to be, and more provision is made forheating wards.

Simultaneously the practice in general hospitals has tended tomove in the oppositedirection, to provide fresh air at a lower temperature than wasformerly thoughtnecessary. There is still, however, a very wide gap between thetwo for which it isdifficult to find sufficient justification.Abundant ventilation in open-air hospitals is not synonymouswith draughts.Sir Henry Gauvain has shown in his new buildings at Alton howthe completestexposure to fresh air and sunlight can be combined withnecessary warmth andcomfort. Draughts are not essential in sanatorium treatment,although in moderatedegree they do no harm. The fear of cold is deeply rooted inpeople's minds, andcertain diseases are particularly associated with exposure tocold, mainly perhapsbecause of the chilly feelings which usher them in. Pleurisyis such a disease.Naturally it occurs frequently in sanatoria because it is partand parcel of pulmonary

tuberculosis, but it occurs in my experience just asfrequently in summer as in winter,and more frequently in the patient's own home than in asanatorium.Lobar pneumonia is practically unknown in sanatoriumpractice. In anexperience of twenty years and covering about 12,000sanatorium cases, I cannotrecollect a single case of lobar pneumonia among them. Yet inthe early weeks, atleast, of their sanatorium treatment, there must have beenamong them as high aproportion of pneumococcus carriers as in the generalpopulation from which theycame. They were plunged into the ordinary conditions ofexposure to sanatoriumweather without any mitigation or gradual acclimatization.They ranged from15 to 65 or more years of age. The initial discomfort which theyoften feel in winter


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generally disappears quickly, and their symptoms of illnessas a general rule begin toameliorate from the time of admission.Bronchitis is occasionally aggravated by sanatoriumconditions in winter, butmore frequently improves steadily with the improvement in boththe generalhealth and the tuberculous disease. Colds in the head occur insanatoria in verysmall epidemics when infection is introduced from without.Neither the generalnor the local symptoms are any worse under sanatoriumconditions in winter than inan ordinary household. Where the coryza is complicated bytracheitis or bronchitis,1414 Proceedings of the Royal Society ofMedicine 80this occurs no more frequently and takes no longer forrecovery in patients nursedin open-air wards even when the temperature ranges somewherebetween 300 and500 F. than in patients nursed in their own homes at muchhigher temperatures andwith much less exposure to moving air. It seems that it is lessthe low airtemperature that aggravates the symptoms of a corvza thanalternations of highroom temperature and low external temperature in winter.Chilblains occur fairly frequently in winter and may beuncomfortable, but sucha trivial complication cannot be set against the greatbenefit which the open-airregime confers on the health of the patients. It is no partof sanatorium treatmentto keep its patients uncomfortable. If they are, itindicates some avoidable failure onthe part of the staff or of the patients themselves.Rheumatic conditions, so often associated in the minds ofthe public with cold,are occasionally complained of by patients. Only twice, Ibelieve, have I seensubacute rheumatic fever develop among my patients, and Isuspect that rheumatismin its various forms is less common in sanatoria than amongthe general population.In two children's hospitals with which I am acquaintedtuberculosis and acute and


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subacute rheumatism are treated under almost similarconditions in regard toventilation and heating. In the acute stages the rheumaticcases are treated infreely ventilated and only moderately warmed wards, and inthe convalescent stageseither on open balconies or verandahs, or in wards identicalwith those fortuberculous cases.In regard to the infectious diseases, spread mostly by sprayinfection, the degreeof ventilation in sanatoria so dilutes the infection that itis rare for an epidemic togain more than a very small footing. During the recentepidemic of influenza 1%of my patients and 25% of my staff were affected. The all-important part that

good ventilation plays in preventing cerebrospinalmeningitis in barracks is wellknown to you.If, then, one is justified in claiming so much benefit tothe general health, andsuch an absence of adverse effects from the degree ofventilation practised insanatoria and open-air schools, the question ought to bediscussed how far the samepractice is likely to have similar results in other diseaseconditions. In certainfever hospitals such treatment is already being given toconvalescents with excellenteffect. In children's hospitals, too, there is a greatertendency to expose patients onbalconies and verandahs, perhaps more for treatment bysunlight than by fresh air.In the earlier part of this century a good deal was writtenabout the value of open airtreatment of cases of pneumonia and the most conflictingopinions were expressed.For example, G. D. Head,' from an experience of Americanmilitary hospitals inwar-time records a mortality of 13 * 9% among cases ofinfluenzal pneumonia treatedby open-air methods, and 3 . 2% among those treated in closedand warmed wards.But it is clear that the open-air methods were undulydrastic, and further the firstfigure was obtained during the early part of the epidemicwhen one expects a higher


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also be of value in the majority of medical and surgicaldiseases ? Pyrexia is nocontra-indication, but is rather an indication for it. Theprovision of balconies andverandahs, although making such treatment easier andpleasanter is by no meansessential, and unless well planned may be a disadvantage.It seems a little absurd that patients of all ages and degreesof infirmity, andsuffering from a great variety of diseases, should receiveidentical treatment inrespect of the very important medium envelopinjg them. Inthe large wards whichhave been favoured in England, the ventilation must necessarilybe a compromisedetermined like the strength of a chain by the weakest link.It seems reasonableto provide the treatment most suitable to the needs of theindividual, and I suggestthat this could best be secured by providing a higherproportion of accommodationin small wards, in which selective treatment would becomepossible.Diffusion of air alone, although with large openings it may besufficient to keepthe chemical composition satisfactory, is nevertheless notenough for good ventilation.It does not as quickly as is necessary remove the layer ofheated air in contact withthe skin. For this some movement of the body of air isrequired.- Air in uniformmovement, causing monotony of sensation, is regarded as lessstimulating andbeneficial than air varying in velocity, and possibly also intemperature. Slow massmovement with such small variations, " puffs of air this wayand that," providesbetter. ventilation than strong currents of air comingthrough small openings andcausing marked local cooling. The most comfortable and at thesame time probably

most efficient ventilation is secured in a shed or room ofwhich one side is completelyopen, while the other three sides, although provided withfanlights, can be completelyclosed. On windy days the velocity of the moving air isreduced to reasonablelimits, whether the open side is towards or away from oroblique to the direction of


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the wind. On still days free diffusion plays the chief part,aided by such crossmovements as can be. secured between the open front and one ormore fanlights inthe opposite wall.The cooling effect on the body which is desired is attainedeither by the coldnessof the air or by its movement. Cold still air does not longremain cold in contactwith the warm body, hence in practice it is the movement ofair at a temperaturebelow that of the body temperature that matters most inregard to ventilation. Agreater velocity of movement is naturally required the higherthe air temperature.With really cold air a little goes a long way to provide theconditions of good

ventilation, and protection from too great velocity becomesimportant. Suchprotection out of doors is of course provided by increasingthe clothing. Indoorsit is generally attained by cutting down air movement, forexample, by closingwindows. Our problem is to secure such a degree of movement ofthe air as willstimulate metabolism by abstraction of heat from the body,without interfering withthe patient's comfort to such an extent as to depress hisvitality by excess of heat lossor to excite in him a hostile mental attitude which wouldtend to counteract thebenefit of the treatment.

Proceedings of the Royal Society of MedicineIt follows from my argument that there is essentially aconflict between goodventilation and good heating as ordinarily understood, indeedthat the two areincompatible in practice. Usually the ventilation issacrificed to the temperature

of the ward, but I hold that the ventilation should be thefirst consideration andthat the ward temperature is a secondary matter. The oldstandards of ventilationhanded down from one textbook to anotber, and based mainlyon the carbondioxide content of the air and on the standard of comfortdemanded, required that


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the air of a room in which each person had 1,000 cubic feet ofair space be changedat least three times an hour. Rosenau states that air movingat a greater velocity

than 1 to 2* miles an hour, that is 1-5 to 3-5 feet persecond, according to theoutside temperature, causes the sensation of a draught. If thewhole body of airin a room were moving at even the smaller of these velocities,it would be changedat least one hundred times an hour. The latter standardcorresponds much moreclosely than the former to the conditions under whichtuberculous patients thriveand get well.One has to consider the psychological effect of any form of

treatment on thepatient. A continuous stream of unpleasant sensory impulses isnot likely toconduce to recovery any more than continuous pain. Childrenare little affected inthis way, and stand exposure to cold remarkably well, as canbe seen both amonghealthy children and among ailing children in open-air schoolsand hospitals, wherethe amount of clothing required is surprisingly small. Comforthas to be studiedrather more in the adult. But what may at first be regarded as

discomfort is soonborne cheerfully and without any harm if the patient issatisfied that thereby hisultimate good is going to result. It has to be emphasized thatexposure to cool airis a mode of treatment and that the body adapts itself veryquickly to such achange of conditions.In this country it is generally held that the ward temperatureshould be between

600 and 65 F., the optimum temperature for comfort being

62 F. In America thestandard demanded for comfort is generally higher, even ashigh as 700 to 75 F.Obviously these figures are partly dependent on habit. Theview now advanced isthat ward temperatures can be reduced below those standardsnot only without harm


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to most patients, but actually with benefit to their generalhealth and the rapidity oftheir recovery. Naturally, adjustments in other directionswould have to be made.Extra blankets, warm bed jackets, bed socks and gloves and, ina few cases, woollenhelmets would have to be available for need. The dietary wouldprobably have tobe increased to meet the increased metabolism. Patients wouldhave to be betterclassified than at present. Those requiring more shelter andwarmth would have tobe segregated in small wards.Mechanical systems of ventilation by propulsion and extractionof air have manyattractive features where equable conditions of temperature,humidity and velocityof air movement are desired, as in an operating theatre or aplace of entertainment,but in hospital wards, where equable conditions areunnecessary and possiblyundesirable, they have quite gone out of fashion both inEngland and abroad.Whatever system of ventilation is used, it is less frequentlythe equipment than thehuman management of it that is faulty.Most hospitals now depend on cross-ventilation of wards bywindows, oftencombined with the ventilating effect of open fires or stoves,

and sometimes with wallventilators opening behind radiators. Tobin's tubes andSherringham's valvessurvive in old buildings and in the textbooks. Fireplaces orstoves in the middleof wards have mostly gone also, not because of inefficiency,but because of theirobstructiveness and effect in increasing the width and thecost of buildings. Windowventilation by itself can provide any degree of ventilationrequired if it is usedintelligently. Too often the fear of draughts leads to the

closing of windows exceptin really warm weather. Ventilation openings behindradiators are closed at the

1416 -8283 Section of Epidemiology and State Medicine1417


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beginning of winter and are forgotten afterwards, accumulatinga deposit of dustand fluff in an inaccessible position. Windows are closedwhile a patient is strippedfor examination or for blanket bathing, and the nurse forgetsto open them afterwards.So long as such things are regarded as of little importance,any system will givebad results. But if we elevate good ventilation to its properplace as a therapeuticagent, a form of physical medicine which is a valuableadjuvant in the treatment ofthe sick, and train medical students and nurses in itsprinciples and application,then even the provision now made by architects will be foundgenerally satisfactory.The practice of heating the incoming air is, I am glad to say,becoming lessfavoured. In view of the teachings of physiology, it seems tome to be wrong inprinciple, unless it is limited to taking the chill off verycold air.With regard to the form of window, sash windows are stillbeing used morethan casements in large wards.' The double hung sash, made ofgood materials andhung on chains, is easy to manipulate and to clean. It doesnothing to breakstrong currents, and of course allows only half the windowspace to be open.Casements allow practically the whole space to be opened, butmay not be regardedas suitable in mental or children's hospitals in view of therisk that patients mayfall out. Casements ought to open outward, even if they aremore difficult to clean,because they can be adjusted very well to regulate theentering current of air, andbecause it is easier to make them raintight. Variations in thedirection of the windcan be met by opening one or other half in varying degree, so

as to interpose a baffleor barrier against too strong a current. Particularly to bewelcomed are the newerdesigns of casement window, vertically pivoted about a thirdof the distance fromits edge. Such a window, combined with friction joints and afastening on theprinciple of the inclined plane, gives a degree of comfortto window ventilation not


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previously attained. Their use demands less intelligence andless constant attentionthan does ventilation by sash windows, while the noise ofrattling stays and thedanger of breakage in a high wind are practically eliminated.The ward window, whether of the sash or of the casement type,is best completedabove by a hopper, hinged below and opening inward to aconsiderable angle. Sidecheeks of glass are a necessary evil, in order that the coldentering air may not falldirectly down on the patient, but may be directed upward anddistributed from theceiling. Some windows are now made with a similar, butconsiderably smaller,hopper along the lower part of the window, which servessomething of the same

purpose as the Hinckes-Bird device for sash windows. It isgenerally agreed thatward windows should be low enough to allow bed patients tosee out, that is, within33 in. or at most 36 in. of floor level, and should extendwithin a foot of the ceilingfor the sake of good lighting and ventilation from theceiling. If, however, theyextend too near the ceiling, the latter tends to becomestained with the rain, andthe amount of glare from the sky is apt to trouble patientsfacing the window.If it is thought necessary to provide wall ventilators, Ishould prefer these to benear the ceiling, sloping upward and inward, and with animpermeable lining. Theinner grating should be detachable for periodical cleaning,and there should be nomeans of closing it.Another type of window which has been commended by theScottish Board ofHealth, but of which I have no personal experience, is theAustral window, the two

sashes of which are horizontally pivoted so as to direct theentering air upward andto keep out rain.Hitherto we have had chiefly in mind the conventional largeward of twenty orthirty or more beds with its long axis north and south. Ingeneral hospitals thetendency towards smaller wards, already mentioned, has gotlittle further than the


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provision of side wards of from one to four beds. In feverhospitals also, the growingdemand for isolation accommodation has led to the provisionof more small wards.Although large wards allow better supervision of patients

and a slight economy ofProceedings of the Royal Society of Medicineservice, they are inferior to a system of small wards, inseveral respects. The latterallow much better classification of patients according totheir disease and therequirements of treatment, their age and social oreducational position, and socontribute greatly to their comfort and happiness. Theybecome more useful themore patients are expected to contribute to the cost of theirmaintenance accordingto their means. It might be thought that the ventilation oflarge wards would beeasier by means of opposed windows, but my experience is thatthe ventilation ofsmall wards gives less trouble and more comfort, and thatindividual needs can bebetter dealt with in the way of providing extra warmth andfreedom from draughtsin cases where such is required. Small wards, each of fourbeds, solve manyproblems of ventilation and lighting where the beds can beplaced parallel tothe window. It is easier to approach the ideal of one sidebeing completelyopen while the opposite wall, generally opening into acorridor, can have asmuch or as little glass as is desired for supervision, andone or several fanlightsfor cross-ventilation on still days. The bogy of dead orunventilated spacescan easily be overcome by proper use of the windows andfanlights. The newer

architecture allows much more window space relatively tosolid wall. A reportto the Royal Institute of British Architects' on theorientation of buildingscontains the following statements: "Whilst public opinionis demanding the mostample admission of light, air and sunshine to the interiors ofdomestic, factory and


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office buildings, hospital wards are still being plannedwith over 60% of the externalwall space taken up by solid brickwork. . . . Wards are nowbeing erected in thiscountry where the actual amount of solid wall now occupies

only 34% of the wallsurface instead of 70% as in the older type of wards. TheCommittee are informedthat the additional cost of maintaining the necessary minimumtemperature in viewof the larger window area has been carefully investigated,and is considered to beimmaterial." These are the views of a strong committee ofexperts.If balconies are desired they should be quite narrow, sayfrom 3 ft. to 5 ft. Widebalconies and roofs of verandahs undoubtedly cut off anundue amount of lightand ventilation from rooms below.Objection may be taken to small wards on the ground ofincreased capital cost,but it must be taken into account that the segregating effectof partition walls andthe higher standard of ventilation which it is suggested canbe attained make possiblea greater density of beds. Even allowing for a centralcorridor of S ft., the floorspace per patient need be no more than 100 sq. ft., and indeedmay be as low as86 sq. ft. without harm in general hospitals. Within limits,floor space may bereduced in proportion as the ventilation is increased.So-called "verandah-wards " have been recently designedwhich are claimed tocombine the advantages without the disadvantages of theward with a verandah.The Dosquet ward described in the German literature is sucha ward. In Englandanother is described in the Report to the Royal Institute of

British Architects alreadyreferred to, which is only 20 ft. wide, and has the side wallsmainly of folding glassdoors, allowing complete access of sunshine and air from bothsides if desired. It isdivided by partitions, mainly of glass, into cubicles, eachwith four beds, parallel to


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the outside windows, and allowing ample corridor spacealong one side of the ward.Heating.-The heating and ventilation of hospital wards are sointerdependent thatthey cannot be discussed apart, and several points in regardto heating have alreadybeen referred to. German writers have certainly gone veryfully into the engineeringdetails, but it is difficult to accept the dictum ofSchmieden that the problem ofheating is now solved, but not that of ventilation. We wouldall agree, I believe,with the conclusion of the New York State Commission onVentilation thatoverheating constitutes the chief ill-effect of air uponhealth. Overheating of roomshas long been recognized as one of the chief causes of

respiratory catarrh. The best1 Journ. R.I.B.A., Sept. 10, 1932, p. 777.

1418 84Section of Epidemiology and State Medtcinesource of heat is a person's own body, and the only problemthat ought to arise isthat of regulating its loss or conservation by ventilationand clothing. But ahospital patient is not in the position of a healthy person,who can by muscularexertion multiply the heat-production of his basal

metabolism by ten to fifteen times,or even in the position of the child in an open-air schoolwho alternates periodsof lessons and physical exercise. For him some supplementaryheat is necessaryin winter, although not to the extent that is commonlybelieved necessary.Heating of the air to be breathed is founded on a wrongprinciple, and is, inaddition, uneconomical. From personal experience we knowthat if the feet, the

hands and the ears are kept warm, the rest of the body willlook after itself.Recognizing the importance of keeping the feet warm,certain schools and churcheswarm the floor to a temperature of from 70 to '750 F. Threesanatoria, to myknowledge, supply warmth to their ambulant patients indining rooms in the same


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way. In the King George V Sanatorium a hot-water pipe justabove floor-levelunder each dining table gives entire satisfaction. Forpatients in bed, electricallyheated mattresses were formerly used by Sir Henry Gauvain at

Alton, but in generalhospitals and in most private houses a sufficiency ofblankets, along with bed socks,achieves the same end. It is the patient's head and upperextremities that requiresome extra heat in winter. If a mild beam of radiant heat couldbe focused onthose parts the problem would be solved. Panel heating byhot-water pipesembedded in the ceiling or in the walls is said by Vernon toconfer the same degree

of comfort with a room temperature of 550 F. as heating byconvection to 650 F.Radiant heat has little effect in heating the air throughwhich it passes, and istherefore claimed to be the more economical. The technicaldifficulties of heatinghospital wards by radiant heat have not yet beensatisfactorily solved, and the oldermethods of heating have still to be relied on.Under ordinary circumstances an open fire in a large ward issomething of aluxury. Its ventilating action should be unnecessary withcross-window ventilationeven moderately well managed. A fire is a necessity if thereis no day-room forconvalescent patients, and it provides for those sittingaround it a comfortablesource of radiant heat. Otherwise, unless it is arranged todeliver a flow of heatedair in the ward, it does little more than pretend to heat theward. Even this andits admitted cheerfulness may justify its use in a largeward freely ventilated in theway I have suggested. Where fires are used in wards they arebest placed ateither end.The objections to steam heating of wards are many-themusty, stale smell, as


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unappetizing as the conditioned air of the tube railways,and the complication ofguards to prevent burns being the chief. High-pressure hotwater has very similardefects. Almost universally employed now is heating by

low-pressure hot water,usually circulated by pump from a central boiler house. Aradiator under eachward window is the usual mode of distributing the heat. Formy part I prefer pipeheating, as being cleaner and ensuring more even distributionof the heat. As itpasses under a window and under the bed head the pipe givesoff enough heat tobear up and allow to be sufficiently mixed the cold airentering at the top of thewindow. A radiator is likely to cause a rising current strongenough to divert thecold air down on the bald head of an adjoining patient. A newform of radiatorwith a flat surface, spread over a larger area and appliedclosely to the wall, is reallya form of panel heating, which offers hope of avoiding theobjections of the othersystems. In theory, radiators in the centre of a ward shouldgive off more radiant

heat and be preferableto

wall radiators, but in practicethis is not so, and twohospitals of which I know have recently decided to go backto wall radiators.Lightiny.-On this subject I am not aware that there is muchcontroversy excepton details. With regard to daylight, the ideal to be aimedat is the maximum ofdiffuse light without glare. The orientation andsurroundings of the hospital are85- 1419

1420 Proceedings of the Royal Society ofMedicine 86relevant factors. In most cases hospital wards face east andwest, since a southaspect generally makes the ward uncomfortably hot in summer,and allows less ofthe floor and walls to be swept by direct sunlight thanwhere the ward faces east


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and west. For the same reason the administration blocks shouldbe at the northend of the wards. It is better to use the south end of theward as a sun-balcony orday-room, instead of placing the sanitary accommodationthere.Sanatorium wards generally face south, or a little east orwest of south, whichmay be of some advantage in winter, and is not of muchdisadvantage in summerbecause of the copious ventilation which is possible.Convalescent wards in sanatoriamay well face east and west.Glare from the sky is often troublesome, especially ininfectious diseases withcomplications of the eye. The discomforts of glare and ofreading in face of a brightsource of light may be unsuspected causes of fatigue andheadache. The really sickpatients are most likely to suffer, since many of them,particularly the surgical cases,are compelled to lie or recline on their back. Naturallyglare is less troublesomewhere the ward faces other buildings or a screen of trees. Thehigher the windowsgo to the ceiling, the greater the discomfort fromglare. Onupper floors especially,it may be an advantage to place the beds parallel to thewindows, a practice that iscommoner abroad than in England. Discomfort from glare isalmost entirelyavoided in the small wards which I commended earlier.The question of blinds and curtains deserves mention.Wherever possible, theseshould be dispensed with, for the sake of good ventilationand cleanliness, as is thepractice in most sanatoria. Patients generally accustomthemselves quickly tosleeping in the evening and morning daylight in summer, butit is recognized thatvery sick patients may be fretted by too much light and maysuffer from the absenceof blinds at a critical stage in their illness, for example,before operation. For themagain selective treatment in small wards would solve thedifficulty. The necessities


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of nursing in wards overlooked by other buildings may makeblinds or curtainsinevitable. Each case must be considered according to itscircumstances.The colour of walls in hospital wards has a good deal to do

with the efficiencyof the lighting. It is now generally reckoned an advantage touse colours which willshow dirt rather than hide it. Very light colours, such aspale green or cream,combine a pleasing effect with nearly the maximumreflection of light. Ceilingsshould be lighter still, generally a "-broken" white.The supply of artificial light should not be niggardly.General ward lighting, byreflection from the ceiling, can be made quite satisfactory

when carefully arranged,but generally wall lighting is preferred. Electric lightshould be supplied over eachbed by a wall bracket and a shaded lamp, with the switchaccessible to the patient.Such a light at a height of approximately 6 ft. from thefloor, and of not less powerthan 25 watts, will provide for comfortable reading by thepatient, and for nursingattention and treatment by the staff, without glareaffecting other patients. In twohospitals known to me, these bracket lights -have their broadbase detachable from aflat hook on the wall, thus providing all the advantages ofa movable side-light forexamining throats or eyes or skin rashes. They have,however, the disadvantagesof dangling flexes, collecting dust, and it is more usual toprefer a fixed wall lightover each bed and, between each pair of beds, a point intowhich to plug a side-light.Dr. Gordon Pugh, of Queen Mary's Hospital, Carshalton,recommends a less expensive

alternative, by which the interval between windows is wideenough to take two beds.One wall bracket light with a spherical white glass shadeis shared between the twobeds. The light is thus oblique, and does not cause glare to arecumbent patient.With a system of lights over bed heads, very few centrallights are needed for


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general illumination in large wards, perhaps one over asterilizer table or drugcupboard and one over a fireplace for the use of ambulantpatients. A shaded lightmust be provided over the nurse's table and one or two ceiling

lightswith inverted

87 Section of Epidemiology and State Medicine1421shades as night lights. The switches for the latter should beseparated from theother switches to prevent bright lights being switched on inmistake at nright.Another minor improvement is the effort now being made toprovide noiselessswitches.Having regard to the times, I have in this paper avoidedreferring to methods ofventilating, heating and lighting hospitals, which, althoughpossibly better thanthose now in use, involve very heavy expenditure. Whenelectricity can be suppliedsufficiently cheaply for heating wards and for regulatingventilation, the time maycome when it will have as complete a monopoly in those servicesas it now has inregard to illumination.Discussion.-Dr. ALEXANDER JOE said that he was a whole-heartedbeliever in the valueof fresh air in the treatment of the acute infectious diseases, and

workers in this field owedmuch to the tuberculosis experts for ideas as to the ways and meansof providing it. Hehad found fresh air particularly of benefit in the treatment ofinfections of the respiratoryand upper air tracts, and generally it induced rest and sleep andpromoted appetite. It hadan undoubtedly beneficial effect on inflamed mucosa and on thataccount probably didsomething to lessen the period of infectivity, whilst the dilutionof infection in well ventilatedwards was one of the most important methods of minimizing "droplet"cross infection.He considered that for the treatment of such diseases as the septictype ofscarlet fever, whooping-cough and measles with their associatedbronchopneumonia, openairtreatmient was essential, and that in the present epidemiologicaltype of scarlet fever,probably the only contra-indication to open-air treatment was whennephritis had developed.


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As to the methods of carrying out the treatment, he was convincedthat open-air withadequate safeguards against strong sun or bitter wind was superiorto a roofed balcony, anda roofed balcony to the open-sided ward. He agreed with Dr. Wattthat in a ward abundant

ventilation was of more iinportance than the maintenance of auniform level of teinperature,and in his own practice he did not worry unduly about a low wardtemperature, but insistedon the body-warmth of individual patients being maintained in bedby hot bottles, adequatepersonal and bed clothes. The latter method, whilst imposing astrain on the nursing staff,could be carried out, and in his hospital patients who hadwhooping-cough and measles wereput out in their cots on the ward balconies for part of the day allthe year round, except ondays when the wind was bitterly cold.Mr. H. W. BINNS showed some photographs of a hospital for totallydisabled soldiersand sailors (St. David's Home, Ealing) of which he was thearchitect. He explained that thishome was built to accommodate the worst type of the incurableillnesses brought about bywar service, such as encephalitis lethargica, rheumatoidarthritis, etc. Practicallv all thepatients were incontinent and from thirty to fifty per cent.entirely bedridden, and it naturallyfollowed that they were inmates for a considerable period.Fig. 1 (p. 88) was a view taken inside the " cloister " which formed

one end of a four-sided"garden courtyard " around which the new wing had been built. Thetwo-storey building onthe opposite side of the courtyard had male nurses' accommodationon the upper floor. Thisphotograph also showed one of the small wards with a certain amountof extra cross venti lationat either end. Mr. Binns drew attention to the domestic treatment ofthe cloisterssuch as the limed oak beams in the ceiling, the design of the lampsand the treatment of thetile floor, etc., all of which, although they did not affect theefficiency of the building, helpedto give it an " atmosphere " different from that generallyassociated with a building of thiskind.Fig. 2 showed the cloisters occupied by beds, as seen from thegarden. The windows onthe back wall were sliding and glazed with " vita-glass " so thatin very hot weather thepatients had all the benefit of being out of doors without thediscomfort from the sull and


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with controlled protection against draughts.Fig. 3 showed the interior of one of the larger wards and attentionwas drawn to the two facedfireplace which had its chimney passing under the floor. Attentionwas also called tothe windows with pivot-hung casements to the lower parts, and

hoppers falling inward abovethe transomes were also shown on this photograph. The colour schemecomprised a brownoak wood block floor, saxe-blue dado and light primnrose buffwalls and ceilings. The windowswere kept low to enable patients in bed to see the gardens, etc.SEPT.-EPID. 2 *

Proceedings of the Royal Society of Medicine

'Iii.Fia. 1.Fxi. 2.

1422 88Section of Epidemiology and State MedicineFIG. 3.FIG. 4.

89 14231424 Proceedings of the Royal Society ofMedicine 90In a hospital of this kind with plenty of land available, and inwhich a one-storey buildingwas an advantage, a cloister was better than a verandah as it did nottake away light from thewards and enabled the patients to have complete change of scene andenvironment and alsoto interview their families in a garden instead of in a ward, withthe advantage of a furtherdegree of privacy.Mr. Binns then showed some photographs of St. Vincent'sOrthopmedic Hospital atEastcote, of which he was appointed the Architect some four yearsago.Fig. 4 showed one of the new wards with similar accommodation to thatin the old type ofward, but designed to be more cheerful, lighter, and better

controlled in regard to ventilation.FIG. G.Fig. 5 showed the new babies' ward which had just been completed,with its broad teakplatform on the south-east side where the three rows of beds whichthe interior of the wardaccommodated could be pushed out. It did not, however, clearly showthe side windowswhich had sliding control, or the sliding glazed screen which couldshut off two-thirds of the


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and a glass roof could be quite intolerable. In such circumstancesone usually found thatthe glass roof had been painted green to exclude the sun's rays.The temperature of wards was usually too high, and the uniformityof temperatureproduced by central heating was bad. Unfortunately, nowadays,

everything was planned tosave trouble and it was less trouble to keep a constant dead level oftemperature than tovary patient's clothing with varying temperatures. It was not sogood for the patients,however. Apart from certain special forms of illness which might callfor uniformity oftemperature, patients, like healthy people, were the better forvariatiolns which called for aresponse from the heat-regulating mechanismis of their bodies.He, Dr. McIntosh, agreed as to the desirability of small wards, butthey caused difficultiesin planning unless one was content with direct openings into the open airon one side only.One side of the small wards was bound to open into a corridor. In thecase of single-storeypavilions, by making the corridor lower than the wards, there couldbe windows openingover the corridor, but in multiple-storey buildings this, ofcourse, was not possible.1426 ProceedTngs of the Royal Society of Medicine92Dr. E. W. GOODALL said that changes in hospital design had been goingon for a longperiod, but they were not always for the best. Some of the hospitalsbuilt a century or soago were anything but an improvement on those erected at an earlierdate. For instance,the surgical wards at Guy's Hospital, which were part of the originalbuilding, were muchbetter as regards light and ventilation than those in the largeblock-the medical wardswhichwere built later. With regard to the height of the windows above thefloor: in thedays when typhus and typhoid fever were very prevalent, the windowswere placed high sothat delirious patients should not get out of them. Doubtless, barscould be placed acrosswind6ws that came nearer the floor, but they gave a prison-likeappearance to the wards.He was surprised that Mr. Pearson anticipated opposition to thearrangement of small wardsof from one to four beds each; he would not meet with objections frommedical men, at anyrate from those who had to do with fever hospitals. But, of course,there was the question


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of cost-both of erection and of maintenance-to be considered. As tothe question of theexposure of patients more or less in the open-air, the publicrequired education; ignorantpeople still had rooted objections to open windows.

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