COLUMBIA LIBRARIES OFFSITE HEAlTH sciences stand* HX64076296 RA966 W85 Air and the hospital RECAP ■ . • .Air a Columbia (Bntoergitp College of $f)p*triang ano Buirgeons Hibrarp AIR AND THE HOSPITAL By Prof. S. Homer Woodbridge Of the Institute of Technology^ Boston Gin OF TEACHERS COLLEGE m 2 n >942 -r/W) 4> 4' s & « *? # « Thursday, September 22 — Afternoon Session AIR AND THE HOSPITAL By Prof. S. Homer Woodbridge Of the Institute of Technology, Boston I. In the remedial treatment of disease, the medical profes- sion of to-day is coming to recognize, and to place inc : ing reliance on, the primal sources of vital energy as their chief and indispensable- allies. The effort of the typical twentieth-century practitioner is to put his patient into the most effective relation possible with those sources of vital- ity. He puts his patient to bed, that his residuum of energy may not be expended in external work, and that it may be conserved and directed to internal repair. He prescribes a diet which .-hall contribute the most to the in< I vital energy, and which shall tax existing energy to the least in the processes of digestion, assimilation, and nutrition. He de- . prescribes, and sometimes obtains in abundance for bis patient that which is tin- co-equal with nourishing food in the production of vital energy, pure air. He reli( the potent helpfulness of a healthful, cheerful, and hopeful mind presiding over the tabernacle it inhabit-, mysteriously affei ting, through will, imagination, and mood, the ni controlled function- of the introactive and interdependent or- gan- of the complex system of the human body. I of all, in remedial importance and use, i- the drug, whose sole and subordinate office it i- to remi to nature'- restorative work, and to stimulate nerve- and ins to normal functions. The pla< e of pure air, in -uch restorative treatment, i- Ond to none. All recuperative work done i- done by vital 3 4 Air and the Hospital. energy. Vital energy is a part and phase of universal en- ergy, transformed from energy, previously and eternally ex- isting in some form, and now, for the moment, vital in its phase. The form of energy from which man draws his chief sup- ply for transformation into either vital or dynamic is largely chemical. Physical life is a process of energy transforma- tion, principally from chemical energy — residing in the rela- tion of the carbon of foods to the oxygen of the air — in- to vital energy. The essential problem of vitality is, there- fore, that of the adequate appropriation of existing energy, and of the transformation of that energy into vital form. The same is true of man's industrial life. The world is to- day producing transformations of energy, in the field of dynam- ics, at a prodigious, almost prodigal rate. On the one side is a fixed, and therefore limited, supply of carbon and hydro- gen in the accessible coal stored in the earth's crust, within man's ready reach. On the other side is an unlimited supply of oxygen. At the present rate of use, — three million tons of coal mined per day, — man is drawing heavily on that fixed and unrenewable supply. In the free air about him are one thousand million millions of tons of oxygen, which, by a wonderful process in the Creator's great laboratory, is re- stored by vegetation as rapidly as it is used in the energy- transformation process called oxidation, or combustion. What is done by man with his fuel and his draft, his boil- ers and his engines and machinery, in changing chemical energy into dynamic energy which he can direct and apply to the doing of his work, and the development of his indus- tries, is also done in the body, animal and human. Food is the fuel; ventilation and respiration the draft; a marvellous and complex organism the engine and mechanism. In its last analysis, the body is an energy transformer of a marvel- lously perfect design, worthy of its creator. The energy, wait- ing transformation, is His also, — the carbon and hydrogen of food on the one side in continuous exhaustion, and peren- nial renewal, so long as sun and moon shall endure and seed- time and harvest shall not fail; and oxvgen on the other side 5 never exhausted, because continuously replenished by the very process which furnishes the carbon and hydrogen supply. Certainly, to the thoughtful student, that order of nature, and the place and procedure of man within it, are suggestive of the permanence of vital energy, and of the transitor of man's materialistic and Babel-like industry, the source of one being perennially renewed, and that of the- other being continually exhausted without the possibility of renewal; one to continue and increase, the other to run its temporary pro- ductive course, reach its limit, and then decline, except as man turns again, as he is even now turning, from the chem- ical energy stored in fuel and oxygen to the gravitation en- ergy of waterfalls and tides for turning his waterwheels, and to the dynamic energy of winds for driving his windmill-. This is man's carbonigenous age, to end with the end of bis coal finding and digging. When mines are exhausted, then may mind- be replenished and heart- be enriched and mel- lowed; and, in that quiet and Less materialistic ome, like the lilies, beings of heavenly beauty and fragrance, when the toiling world stills its busy bustle, and the industrial brain ceases to spin it- prodigies i if energy using and consuming de- The placing of man in his normal relation to the infinite and eternal energy, out of which I . and in which he "lives and move- and ha- hi- being," i- the fundamental truth upon which the study of our subjeel must be based if our thoughts an- to be rightly conceived, and an- to issue in correcl conclusion and in intelligent action. The time will come when, through an enlightened science in reverential i o ordination with divine Christology, there will .ome forth, as there has nol y< I ■ omi ( Christian, and a Christianity which is -rientilu ; when the " I am that I am,'* the infinite and eternal energy, shall be universally, and in everythii that which is "all and in all;" when all work directed by man, in the driving <>t' his enginery, in the propulsion of hi- ships, in the speeding of his train the night of his i annon shot, in the work of his hand-, in all the varied voluntary and involuntan activities of his b 6 Air and the Hospital. shall be reverently thought of as done, not by the now so- called man-created and boasted power of steam, nor by the self- developed power of the body, but by the eternal energy, name it as we will, one with God Himself, put within man's reach and made available to his use in coal and in air, and in other stores of power not man-made but man found and used: a part of that infinite energy which "was, and is, and ever shall be," — the "I am" without which nothing is. The function of the physician, and of the hospital, is to bring the physical life of man into the largest, surest, most lasting, and most active relation with the sources of his vital energy; to put and to keep the human body, that composite system of energy appropriation, transformation, and utiliza- tion, into a complete and effective relation with the energy environment which is both the origin and continuance of all his being and activity. In the past, the physician's function has been pre-emi- nently restorative in character rather than actively construc- tive; it has been healing rather than preventing. Inevitably, however, the logic of the professional work of the physician has produced the science and the profession of hygiene, and to-day the medical profession is one of vitality protection and increase, as well as of restoration. It therefore stands close to Creatorship and to healership, and at the very pinnacle of humaneness — for the reason that the primary, but most unremunerative, work of production reduces the secondary and most remunerative work of restoration. Therefore, in the animus which inspires it, as well as in the service which characterizes it, the profession, as it becomes less one of med- icine and more one of hygiene, is justifying the high Scrip- tural honor bestowed upon it in likening the Great Revealer of Truth, the incomparable Restorer of Humanity to truth- ful relations with its infinite environment, — in likening Christ to the human physician. In discussing the relation of air to vital energy, we are therefore plainly dealing with one of the most important of the basal truths of man's relation to, and dependence on, the Woodbridgc. 7 sources of energy which are placed for his appropriation and use in the carbon of food and in the oxygen of the air. If the study of that subject is to lead us to truthful, and therefore right, conclusions, it is essential that no relevant laws or facts of that relation be slighted or minimized. If food abounds, — and carbon is abundant in all foods, — and if air is free and without so much as an approachable limit, and oxygen is present in fixed proportion in all pure air, why, the mind careless of the nicety and exactness of truth asks, Why all this discussion and agitation and legislation about ventilation? The fundamental truth or law on which the demand for ventilation is based is this: though nature's resources and operations are vast, her methods and requirement.- are neither coarse nor haphazard nor approximate, but exact ; precise to the extreme. The great worlds composing the solar system are as perfectly adjusted in celestial balance as are the atoms which combine to make up any substance exactly proportioned in chemical balance. Remove so much as a planet's satellite from the solar system, and the whole order of movement and relation of the. organic bodies is altered, though the causal change is but one one-hundred millionth of the system's bulk. The variation of one thousandth in the carbon entering into the composition of the hardest of useful steel 1 banges it into a comparatively useless metal. A change of one -i.x hundredth in the make up of the air. by removing it- oxygen and increasing it- carbonic gas, de< n the normal intensity of a candle flame burning in that air thirty six hundredths. The exactness without variableness tiled natural law i- not lessened either with the infiniteness nor with the infinitesimalness of that which i- subjei t to that law. Neither vastnes resource in anywise, nor in any d< exempt the user from that law. The air a- it exists in the open i- perfectly and exactly adapted t«. man'- vitality and to hi- industry. I ' the proportion of oxygen, and hi- vitality exhau-t- itself in its 8 Air and the Hospital. intensity. Decrease the proportion of oxygen, and vitality droops, languishing in the dullness of its unsupported fires. In his industry, man may at will quicken or lessen his fires, the combustion process of energy transformation, by increasing or by decreasing draft; that is, by increasing or reducing the supply of oxygen to carbon. Were the air all oxygen, the coal of his fire, the iron of his furnace, the flesh and bones of himself, the material of his building, would flash into a form of energy for which his disembodied spirit would certainly have no earthly use. The air as it is is meant for human vitality and for human industry as that vitality and industry are designed to be. The air as it is, and exactly as it is, in the open, is meant also for vegetation, as vegetation by nature is created and sustained. The heating-pipes which warm the conservato- ries at Mount Vernon, that sacred Mecca on the Potomac, were not long ago covered with an asphaltum paint. It was in early summer, and the paint was allowed to dry and to harden until the middle of October, when pipes were heated for expelling all deleterious vapor before the plants should be returned to shelter. The pipes, when heated, yielded scarcely a trace of the odor commonly following the first heating of newly painted pipes. The air seemed free from all unnatu- ralness, and the plants were placed for wintering, and, as the result proved, for dying. Again the pipes were heated, hot and long, and the conservatories were ventilated, until no trace of impurity was detectable to the most sensitive olfac- tories; and a new stock of plants was then procured and in- stalled, only to yield their life also to that undetectable, in- finitesimal something which neither the most exquisite sense of smell nor the most sensitive chemical balance could de- tect. Again the pipes were heated, and the enclosures given a prolonged airing; and the leaves and the blossoms of other plants whitened at their edges, and the whitened fringe spread toward the centre, until the leaf withered and the flower faded. Not until those pipes had been heated in the hot blaze of a blast furnace-lamp, and the last remnant of that volatile ethereal something had been driven from the paint, and even Woodbridge. from the absorbing iron, was the life of plants made safe in those conservatories. Such is the testimony given by the (lame of the candle and the flower of the plant to the law of exactitude in the vital processes of nature. If the senseless flower and the insensi- ble flame are subject and keenly susceptible to that law, how much more the human organism, with its complex and ex quisite sensoria, with its imagination and thought, and their reflex influence on vitality and the vital processes! Known to you, better than to any other class of students and obsen ers, are the benefits which changes in the air, from vall< mountain, and from mountain to seashore, work for patient- — though neither chemist nor physicist might be able to measure the atmospheric variation producing the change. Such is the convincing, if not the invincible setting forth of basal truths which lead up to the conclusion that, if vital- ity is to be sustained at its best, the energy containing air must be maintained at its best. Abundance, arid therefore purity, of air is of more impoi tance to the boiler furnace than is quality of fuel. With a poor draft the mosl successful and faithful fireman can do little, even with the best of COal. With a good draft he Can make and keep a hot lire with poor coal. So also for vital tires purity of air is more essential than is purity of food. The on»- is created and provided without human instrumen till it \ ; and environed in it man continuously lives, and of it he as continuously breathes. Food, made or provided through human instrumentality, IS partaken of only at inlen als. I lowevei viewed, as to origin, continuant e of use, .1- to important e of purity, air rank- above food in vital important e. Ki>ks attending dangers an- proportional to the oatun exposure to them. Kisks m: ,y be measured first by the phya ical status, or susceptibility, of tin- one exposed; and second by tlir character of the menace; and third by the time or duration of exposure t<> the a< lion of the Qai A two minutes' dash lU pOSS a battle field i- hazardous, but a si\ hours' stand on the firing line is more s (1 l>y |,n i o Air and the Hospital. also in reference to susceptibility to dangers lurking in im- pure air, — impure by impoverishment, by moribific con- tents, gases, vapors, microbic or other dusts. Some breath- ers have such a reserve of robust vitality that the effects of exposure are so slowly cumulative as to make exposure of short duration attended with small risk. Others with depleted vitality are quickly and obviously affected by pathogenic con- ditions to which the stalwart are immune. Ventilating work, when intelligently planned and faith- fully performed, takes due cognizance of the foregoing fun- damental truths and principles; and of the laws of nature on which that work must be based if it is to be correct in appli- cation and effective in results. It regards the hospital as the retreat of vitality depleted through the shock of accident or the waste of disease, and therefore the place of all others where the physical condition of the subject demands the full- est purity of vitalizing air. Furthermore, the time of dura- tion of exposure to conditions maintained in the hospital is long, compared with that of exposure to the air of theatres, lecture or music halls, or churches, public conveyances, land or sea. Temporarily, for longer or shorter periods, the hos- pital is as continuously occupied as is the dwelling-house, and more so than the office and the school building. The two considerations, therefore, of the state of susceptibility of body, and also of the time of duration of exposure, conspire in the demand for a more free ventilation of hospitals than of any other class of buildings for human occupation. Vital depletion, duration of exposure, and the specific dangers to which patients are exposed vary within wide lim- its within the hospital itself. Some effluvia which permeate the air of hospital wards are emanations from those afflicted with contagious diseases. In such cases, ventilation should perform the triple office of invigorating the patient, of diluting the germ dust, and also of protecting those uninoculated by the disease. Such work requires the maximum per capita of air-supply called for in good ventilation. In surgical wards are those reduced by the shock of oper- ation, augmented, it may be, by that of accident. In the Wo these several parts of the hospital ? No air can be too pure for the need and use of the most virile vitality — certainly not for impaired vitality. It atmos- pheric impurity is to be maintained at a minimum, then at- mospheric quantity must be maintained at a maximum. Why, then, limit quantity, when air i- free, and environ- US greal ocean, world wide in expanse, and whose fathom mil. Be >me things other than atmospheric taint equally insufferable and hazardous. Chief among thea draft-, drafts on the purse and draft- on the person. En- durable drafts on the purse arc directly proportional to the Volume and valu.- of the individual hank annum. 1 I the person an- inversely proportional to t! \pita vol- ume, or space, within the room ventilated. i 2 Air and the Hospital. The larger the bank-account, and the more spacious the rooms, the greater the per capita air-supply may safely and profitably be. The United States Senators, with the country's mines and the country's mints behind them, and housed in a spacious chamber, are given a minimum air- supply of 150 cubic feet (40 bbls.) per minute. The official inspectors for the State of Massachusetts fix the minimum for scholars in the public schools at 30 cubic feet per minute — for reasons of bank drafts and air drafts. If gain to health were proportional to air-supply, a use of the largest possible supply might properly be urged, as also an unlimited spaciousness of rooms which would permit of the use of such air quantities without drafts. Such, however, is far from the fact. The resulting incre- ment of vitality gain falls off with each increment of air-sup- ply. The ratio of that gain is almost inversely as the ratio of the air-supply. On the first 100 cubic feet of air per capita per hour hangs life or death. On the twentieth 100 cubic feet per hour hangs a certain degree of vivacity, or its ab- sence. On the Senatorial ninetieth 100 cubic feet of air-sup- ply per hour hangs not so much as a single Senator's vote on a private pension bill! Somewhere, the minimum and the maximum limits for air-supply must be placed. The hospital is not a fitting sub- ject to invite a discussion of such minimums. Of all places, the hospital is the place for maximums in all that can in- crease strength and restore health, and, therefore, most of all, in air. Everywhere, but most of all in the hospital, the rule of ventilation should be, "The maximum admissible, rather than the minimum tolerable." The cost of warming air for ventilating purposes, where coal can be had at $5 per ton, and where the outside climate during the closed season averages 35 F. below the indoor temperature, and where fuel is not badly wasted in fires, is twenty cents for each 1,000,000 cubic feet of air used, equiv- alent to a per capita supply of 4,000 cubic feet an hour for ten days of twenty-four hours each, or, roughly, two cents a day for 100,000 cubic feet of pure air! Woodbrui^e. 1 3 If it be possible, by such a pittance in expenditure, to pro- vide in any other way the essentials for energizing human vitality, whether it be in restoring the sick to health or in qualifying the well for the most virile life and productive work, let some one, yet unknown, if not unborn, bless his race by dis- closing that yet undiscovered boon ! What supply, then, shall be given to those sick with infec- tious disease, to restore vitality, to dilute and remove the moribific contents of air, to protect those uninoculated with the disease? A maximum of 8,000 cubic feet per hour for each bed is surely a rational demand. And what for the sur- gical ward, where life often hangs by a thread, and the vital flame burns low, and microbic dusts are liable, and should be absent ? Surely, a per capita supply of 6,000 cubic feet an hour is a moderate maximum. For the medical ward, and for average cases, that limit may be fixed at 4,000 cubi( an hour for each bed. II. Passing from general principles to -"me of the more cific methods to be followed in tin- ventilation of hospitals, tin- first suggestion relate- to the importance of so ventilating some parts <>f the hospital as to protect others than the patients occupying them ; or, in other words, the use "t such a method of ventilation in particular cases a- shall prevent the escape of air from the affected rooms to other rooms, <>r to 1 orridors connecting with such rooms. Such ventilation, to be effective, must effectivel] isolate that room, atmospherically, from its surrounding-. To 1 mplish that result, its provided dis- charge Mutilation must be in 1 of it- provided supply ventilation. Rooms requiring such so-calli tilation *' are contagious wards, privati ml. sanil operating, mortuary, etherizing, and bath room-, V: quarters, lockers, and lavatory rooms. Themaji iper ating to ventilate those room- should be on the side of istence upon relief imperative. Reluctantly, John lowered himself to the floor, reached over the berth to the window at its foot, and with some effort and, let it be hoped, affection- ate warning, and with deliberate and delicately solicitous in- tent, raised the inner sa>h of the double window, and climbed back to his berth. In a few minutes all was quiet below, and sleep for the remainder of the night was as sound and sweet as that of tin- just. The conditions remained unchanged, except that the inner sash was lifted, while' tin- outer sash re- mained tightly closed; but imagination was gratified, and sleep was induced. The purpose "f ventilation is definite and simple. What ever legitimately contributes to the attainment «>f that pur- is a proper, and may be a most important, auxiliary means to the end. The rellex influence of mental mood and action is potent and keen and must not be discounted 01 minimized. The nose must not be offended, although there- be nothing noxious, per se, in the offense. 'I'lu- eyes must appeal to satisfying rather than to disturbing sensibilities. Therefore, water-closet and urinal odors should be confined I ,nl\ ,i jpo ible to their appropriate plat < 3, and rem without escape and without mixture with air for Invar notwithstanding the obvious and universal fact that the pel 1 8 Air and the Hospital. vie offenders are individually and continuously within a rel- atively few inches of the sensitive olfactories, and the draft of air moved through the chimney-like space between the skin and the clothing is from pelvic to nasal regions. It is not al- ways those most cleanly in person who are most vociferous in their outcry against the imaginary evils of the offensive air of sanitary quarters. Applied to ventilation work in general, a rule which may be safely adopted is that the evidence of ventilation should accompany its action. Such evidence should be everywhere reasonably conspicuous. The inflowing and outflowing air- way, so far from being concealed, should be attractively vis- ible. The air-flow through such ways may be made help- fully evident by fluttering ribbons. The floating and wav- ing of belittled "Old Glories" in the stream of air entering rooms from supply registers have been used to contribute their optical effects to securing the hygienic ends sought. First of all, ventilate, appropriately, efficiently, thoroughly, and then impress upon the subject, by all needed and legit- imate means, the fact of that ventilation. III. How shall ventilation be done? What method is best? What means are most appropriate and desirable ? What sys- tem is ideal? Such large questions cannot be treated with practical profit in a discussion limited to minutes. Ways, and means, and systems are many, and circumstances have as much to do with determining specific fitness as symptoms, and schools, and the professional or the patient factor have to do with de- termining prescriptions. As in the practice of medicine the physical factor of the patient must be consulted and regarded, so in the engineer- ing practice of ventilation it is found advisable, and some- times highly important, to pay due regard to the physiolog- ical idiosyncrasies of the client. There is, however, one method of ventilation which, when Woodbridge. i g admissible, is incomparably the best in simplicity, efficiency, and economy. The method is the wind, and the means the windows. In the quantity of air moved, and in the effective- ness of ventilating-work, human ingenuity and enginery can- not approach the results obtained by perflation. Artificial ventilation can, at the best, be only a substitute for such natural ventilation. Artificial ventilation is necessa- rily no more, nor no better, than a substitute for that which is natural and perfect. No forcing of air through provided ways and ramifying flues by spanking it with paddle fan blades, or putting it under the screws of the propeller fan, or torturing it with the hot irons of steam heaters can make it do all it stands waiting to do if given the adequate oppor- tunity for doing its own work in its own way. The insuperable obstacle to the universal and continuous use of the natural or open window and door method is in tin- nature of out-of-door climate during the portion of the year when artificial ventilation must be resorted to. Only in tin- equatorial zone and adjacent territory is free and abundant ventilation by nature's methods possible during the entire year. In the temperate and colder zones artificial warmth must be maintained in buildings for occupancy during fully one half or more of the year. Outside cold must be excluded; and as air in its natural condition cannot be admitted with- out also admitting cold, a limitation must be plat ed upon the air supply, and therefore upon ventilation. That fact, how ever, docs not wholly preclude a use of the natural method, even in the i old of the northern winter season. What cannot be i ontinuouslyused with safety maybe temporarily used with profit. Wards, living rooms, dining rooms, almost all <|iiar ters of the hospital, may be advantageously flushed with an inflow, through flow, and outflow of the purest, most invig orating, and hast "doctored and manipulated" air obtain- able. For the purpose of making such a method of ventila- tion usable and useful to the maximum, architects should provide U of water over which it flows, the air current musl move, and equally move, every part of the air of tin- room which it is furnished to ventilate. How shall this diffusion of move ment be effected? It may be done in variou> ways — some elaborate to a degree wholly unnecessary; some simple, yet effective. In the distribution of air through rooms nature comes to the aid of artifice, and, by an engine like action be tween heat and cold, the chilliness of wall LSS throw down, or pro ipitate, air all about the perimeter 0! rooms; and the rays <>\ solar heat, warming iloor-, and other heal within the room sel columns of air in upward motion in 1 centres. The total effeel is, then ton-, to move and mix the whole mass of air inclosed within the wall-. To this pn man may effectively contribute by his method of entering. diffusing, and discharging air: or he may wholly disn the natural movements of air within such room-, and 1st nature in tin- process he proposes, [f h< skilled, he will in each case note nature' tion, and make his own work co operative with natui 22 Air and the Hospital. Though he may give little heed to nature's part in the proc- ess, the correct designer of a method for air-diffusion must yet appreciate the necessity of evenly distributing and dif- fusing the air employed. If he is versed in methods, or re- sourceful in devising them, he will be able to suggest a va- riety of courses to be followed, according to the circum- stances which may require or favor them. Distribution may be effected by either of the following general methods: first, through a multitude of scattered and well-placed points for inflow and for outflow; or by a single point for inflow and many distributed points for outflow; or by a single point for outflow and many and distributed points for inflow. The usual, and the usually adequate, method is to concentrate either the inflow or the outflow into one, two, or more points, and to so distribute the apertures for the opposite service as to effect the desired distribution. For certain reasons to be now mentioned, preference is to be given to a diffusion of supply and to a concentration of discharge. First, if wards are warmed by the air which ven- tilates them, heat is better distributed by issuing into a large room, as a ward, at many points, rather than at a single point. In the second place, draft effects are much less for equal vol- ume movements and equal apertures when they converge for discharge than when the concentrated current of inflow con- tinues its shaft-like course athwart the room. An indraft of air will move in more or less compact current from one side of a room to another, or through the entire length of a ward; whereas outflowing air moves towards its exit through that part of a sphere which is made possible by the conformation of walls and floors, and the flow becomes perceptible as a draft only with more or less close approach to the aperture of dis- charge. Therefore, concentration in outflow is less open to objection than aggregation of inflow. The most convenient, as well as the most effective, place for the inflow of air into wards is beneath windows. Fresh air is then issued into the wards between beds and close to patients, and the current of cold air flowing down over the windows is met and neutralized by a flow of warm air rising Woodbridge. upwards beneath the windows. Ideally, such an inlet should be beneath each window. If, however, they are placed at alter- nate windows, each bed has then a supply furnished on one side. The unused wall-space between cots at the remaining windows affords table accommodation to each bed. The position of the register in such a location should be high enough above the floor to prevent the register-box from be- coming a dust-receptacle, and low enough below the window sill to issue the air sufficiently near the floor to prevent cold- ness at the floor-level. With such an arrangement for warm air inflow, the loca- tion of discharge may be through a single large fireplace and flue at one end of the ward, provided the ward is intended to accommodate not more than ten or twelve beds. If tin- number of beds exceeds twelve, the discharge would better be separated; as in a ward for twenty-four beds a vent would better be provided either for each end of the ward, or at the central point. Roughly, then, in accordance with such a plan, each twelve beds should be furnished with not less than six inlets, and with not less than one ample and well located vent. The practice of locating a vent under each bed is in the direction of unnecessary, though not useless, elaboration. The breaking -up of otherwise continuous floor-surface, the harborage afforded for dust, the in way cess of either n ttr faces flush with the floor or of collars protruding above the floor, for the purpose of protecting the airway against the flowing in or sweeping in of floor dirt, ie princi- pal objections to the arrangement. So far a- mi.1i locations of vents serve to limit the spread and to efTed the quick re moval of bed and lore, and SO far BS thev may be made useful by means of caps and flexible tube tionS— tO ventilate the bed between sheets in , rive discharges from rectum or open sores, such ventil elaboration- arc to be desired. Only in exceptional - however, are they essentia] or even important. Th< necessary toeffei tive distribution of air. Thev ra able in exceptional case-, for localizing odon and impir Other parts of hospital- than wards require adequate, and 24 Air and the Hospital. in some cases special, ventilation. The operating-room calls for exceptional treatment, both in the matter of ventilating and warming. The depressed condition of the vitality of the patient makes free ventilation imperative. The necessarily scant covering for protection from the chill, and exposure to the cooling effect of active radiation to a large area of cold window-glass, demands an elevated temperature of the room. The temperature conditions which are absolutely necessary for the protection of the patient are often distressing to the operator, whose work is in itself most taxing, intense, and critical for the patient's life. The high temperature called for by the impassive and nude patient is oppressive for the operator. For him, and for attendant nurses, there are liable to be moments when immediate, though it may be but temporary, relief from oppressive heat, ether vapor, and the general breathlessness of the air are needed for freshen- ing the operator, and even for insuring the success of the op- eration. Quickness of air-change is then called for. The change desired can best be effected by giving strong exit to the air of the room from its ceiling, where air is hottest and vapors are densest. The air is commonly and properly dis- charged from such rooms at ordinary times near, or at, the floor. If the area of the floor-discharge airway is of proper size, the flue having connection at the ceiling may be of equal size. A large office fan electrically driven may be placed in this opening, the press-button, or switch, for operating the fan being within easy reach of the surgeon or his attend- ants. The current which controls the fan may also operate a damper for closing the opening when the fan is not in oper- ation, and for directing the outflow to the vent at the floor of the room. It has been found by experience that by the use of such a single device the quality of the air of an operating- room may be given the quick change desired for the reduc- tion either of temperature or other oppressiveness or offen- siveness. If the room is of the amphitheatre type, accommo- dating a large number of clinic observers, a fan of suitable size and power to meet the special conditions is required. The air supplied to operating-rooms may well be filtered Woodbn 15 either through an effective wet and germicidal filter, — which may be made of some thirty-six inches in depth of finely broken coke sprayed and wet with a suitable germicidal fluid — or else through a sufficient thickness of sterilized cot- ton-wool. Both processes require a greater pressure of air than that usually available for entering air into low build ings by gravity action; or else excessively large surfaces of filter and correspondingly low velocity of air-flow through them, as where the air-flow is that obtainable by gravity action. For the ventilation of sanitaries, bathrooms, Lockers, and of other quarter.-, a slight reduction of air-pressure within such rooms should be maintained in order to insure B How of air toward and into them from adjacent quarter.-. It then becomes necessary to produce in the vent-flues for such rooms a stronger aspirating action than obtains in the ordi nary ventilating-llues of the building. Thai >f "pull" may not move a larger air- volume than is moved by other flues. The flue with a stronger "pull" may move less air than Hues with a weaker pull. The essentia] is the "/>/ ten or fifteen or sometimes twenty degrees. Roughly -peaking, when such flues ate heated by steam -111 I.m e tlie minimum amount of that be safely used is five square feel I ( rose section of flue. An hour - - discussion might well be given to the sub of the hygiene of ventilating flues thei iuch, perhaps nol too nun h, ha- been written and spoken in n 26 Air and the Hospital. to the importance of keeping airways, both supply and dis- charge, scrupulously free from dust and dirt. Cleanliness is the first essential; to it ventilation is secondary. Cleanliness must always precede, if ventilation is to succeed. Dustiness and dirtiness are less of a menace, however, in some places than in others. If the dust is in a flue through which air is continuously passing outward from a room, the room is in no way endangered by the presence of such dust and dirt. If, on the other hand, the menace lurks in the airway from which the room is supplied, the danger is the greater. We concern ourselves little because of the pollution poured into a brook or river rfoirw- stream. We are, on the other hand, very — and rightly — particular about the purity of the w^-stream water, if the stream be the source from which our supply is taken. Except for the protection of the vicinage, it matters little what may flow out and away from the hospital. That which goes in is of transcending importance to the hospital itself. That which goes out from the hospital may be so treated, if necessity requires, as to remove all offensive and all infectious quality from even the discharged air, by means which cannot be here described or discussed. The principal danger arising from dusty vent-flues is in possible draft reversals, which may carry with them the ob- jectionable dust into rooms. The larger danger incident to the lodging and collecting of dust in the supply-flues is in the movement of air over such dust and into the sick-rooms, the air-current supposedly carrying with it particles of that dust loosened from the deposit, and sometimes dislodging consid- erable quantities of the dust in layers, and carrying it for- ward with the current into the wards. Such a situation is assuredly bad enough, yet not as bad as it might be pictured. The dust belched forth into the wards on certain occasions would be that dust which would have entered in continuous current had it not become at- tached to, and held by, the surface of the piping. To that ex- tent, therefore, the air-supply to the wards would be filtered, and therefore purer, for days and weeks, and it might be so for months and vears — until in a moment's time the reserved Woodbridge. accumulation is discharged into the wards. Meanwhile, how- ever, a change takes place in the quality of that dust, ex- posed for a shorter or longer period to the blast of air over it and through it. The fact has been proved that microbic dust when exposed to air in continuous and rapid movement over it is reduced by slow oxidation to inorganic form. A series of tests made at the Massachusetts Institute of Tech- nology on dust accumulated in air-flues points stronglv to the fact that such oxidation and reduction does take place in the dust of airways; and that. SO far from being the feeding and breeding grounds of microbic organisms, it i- almost wholly free from germs. In so far as that is true of dust exposed to continuously moving air, such dust is the less to be feared on hygienic ground.-. Nevertheless, if for no other reason than for the sake of cleanliness, all lodging and hiding places for dust are to be avoided. As far a- is practicable, all airways may well be accessible for the purpose of inspection and cleaning. For this reason, the mouths, throats, and duct- way- of flues, both for supply and for discharge, should be a- open and accessible a- are fireplace- and their line-. IV. The means appropriate for the propulsion of air through the ventilating system of a hospital art- dependent on a va« riety of < in umstances. Whenever, without too great con on in the matter of mechanical accommodation, in Sizes and places ami form- of airway-, nature i- ready and able, unaided, to do needed ventilating work, that work may iely and wisely intrusted to her. II' r demand acting, ami her performance is a- variable ami fitful a weather and wind. She mu-t be given capacious air* gauged to ;k . omplisfa results when her mood- of temperature and wind an- least favorable to obtaining them. Flue bot toms at ground and flue top- at roof mu-t be given mo vorabl( exposure for her inkle play upon them. Dam] and similar devi< es, mu-t be employed to . Ik i 1. her frov in gales and in < oldness, '■•• hi h reining 28 Air and the Hospital. and curbing, the extremes of excesses in ventilation and in coldness of building would be reached, and when the two ventilation-drafts would become insufferable. The substitute for nature's method and work is ventilating mechanism, — as the fan, — or else a boosting of nature by as- sisting her work by lending her heat, which she seldom if ever returns. Mechanical ventilation is to gravity ventila- tion like the steam-driven to the wind-driven ship. Steam and enginery are indispensable to an invariable speed, to a steady course, and to the schedule sailings of a ship. Yet the sail has not been, and never will be, wholly displaced by the screw. It remains a thing of beauty, and of world-wide service. So also the larger part of ventilating work the world over is to-day, and always will be, done without mechanism. Where the airways for ventilating work can be large enough, and high enough, and where heat need not be used for the sole purpose of producing ventilation flow, there ven- tilation by gravity action is always admissible, and often, if not generally, preferable. When the ventilating work to be done is small, and even when the volume of air used is large, but its use is intermittent and at long intervals, then gravity rather than mechanical ventilation is found advisable. Small and intermittent ventilating work does not warrant the ex- pense of an adequate and largely idle equipment and the salary paid to a competent engineer. This phase of the ven- tilating problem resolves itself into one of operating profit and loss, into which enter too large a number of factors for discussion, or even mention, in our present study. In general, however, this rule may be followed : when ven- tilation is to be continuous, as in the hospital; wherever the air volumes are, or should be, large ; where airways are long, or small, and the velocity of air- flow must be high; where power is available in steam used for other purposes, or in electric service, or in an inexpensive water head and flow, or even when gas or like engines can be advantageously used; when required attendance may be given by those already employed for other service; — then the conditions are fa- Woodbridge. 29 vorable to, and frequently require, the use of mechanical ventilation. An argument made in some quarters against mechanical ventilation for hospitals is based on the necessity of quiet- ness about the sick, and on the assumption that the use of mechanism necessarily involves the noisy whirl of wheels, or the rumbling or clattering of machinery, or the whistling or the singing of the air as it frolics into or frisks out from rooms under the propulsion of the fan. All such noisy nui- sances are quite as avoidable as they are possible. A frequently used substitute for the fan is heat in vent- flues. To warm air for admission to buildings is quite costly enough. To again heat it as it takes its flight from buildings is to increase expense ill a manner to be justified only when other equally effective methods would be equally or increas ingly costly. Because the flue heating method is simple and easily ap- plied, and because it- I OStliness IS I urrcni. -lowly cumulative, and not conspicuously evident, it is often employed to tlie user's lo>s. To move a cubic foot of air into a building through a heater and fan, and through flues to room-, and through rooms into and through vent Hue-, and to discharge it outboard, all that work should require a power rarely nai hing, and never exceeding, that required to raise ten pounds in weight through one fool against the pull of gravity. In a well designed, accommodated, and installed system of ventilation the work expended on each cubit foot of air moved through it should not exceed from five to six pounds. If. on the other hand, that ( llbic foot of air moved through the building is made to move through the ventilating system of the building by giving to it a rise of temperature of ten de . for the purpose of producing an acceleration of flow, the power equivalent of that heat is ten pounds raised through more than fourteen feet against the pull of gravity, instead of ten pounds raised through one foot. If only one twelfth of the heal produced by fuel combustion is convertible into • r, and if the exhaust steam of the engine furnishing that power is wasted, the COSl of moving the air by raisin/ 30 Air and the Hospital. temperature ten degrees and the cost of moving that air by exceptionally hard fan-work are then about equal. If, how- ever, the exhaust-steam from the engine driving the fan is used for heating purposes, the largest cost which we may consider allowable by the fan method is about one third of that by the heated-flue method when the rise in flue-air temperature is but ten degrees. The higher the rise of that temperature the greater the loss. Fan-ventilation is therefore to be generally recommended for large hospitals of complicated plan and construction, where airways must be small and tortuous and long, and where gravity cannot be given generous provision for its own mod- erateness and variableness of work. If the conditions which should determine the use and the avoidance of fans have been correctly stated, there is manifestly one class of hospitals to which the fan is generally inappropriate. The cottage hospital is ideally adapted to gravity venti- lation. Beneath its wards can be great chambers, reservoirs of pure air. Those chambers, instead of being cellars, — dark, damp, dismal, dirty places, the abode of toads, spiders, and creeping things, where the pale, sickly life of plants runs out in slender, eager tendrils toward the little light which fil- ters through some cobwebbed window, or chink in the wall, — should be places flooded with light; flushed to the full with purest air; as dry as sun and air and impervious walls and floor can make them; clean as, if not cleaner than, any other part of the hospital above. The ward is then, as it were, supported in mid-air. Pure air is above it, beneath it, on both sides of it, ready to flow into, and to flush, the ward whenever and wherever its serv- ice is appropriately solicited. Let the inlet way be by an open window on each side of the basement chamber, one-third square foot area of open- ing per bed in each opening; let light and self-operating checks be designed and placed for freely admitting air on the windward side, and for preventing its escape on the lee- ward side; for each two beds let one indirect heater be hung Woodbridge. 3i to the ceiling of the basement, each heater to contain not less than fifty square feet of radiation, for the Philadelphia win- ter climate; let the heater be connected with the ward above by sheet-metal boxing, an air-pipe of one square foot cross- section, and a register grating of one and one-half square feet gross area; let the ward discharge-ventilation be through two-ninths square feet of heatable flue for each bed; let mix- ing-damper- control the temperature of air inflow, and throttling-dampers the volume of outflow; then, construct- ively, the situation is complete for abundant and effective gravity ventilation, one to which a fan would be as much out of place as would be a windmill erected to help out a surplus of water-power. When, however, the river runs dry, then the windmill finds its opportunity for serviceable performance. So also when, in ventilating work, the outside temperature is so high that mildly heated vent-flue- become ineffective, then the fan may be most serviceable. The period of such needed servi however, 50 short that its work had then generally better In- done by a temporary and judicious use of window-transoms, or of windows themselves, if tr.uiM.ni> are wanting. If the wards are cooled in summer by filling the indii radiators with cold water, and by passing the ventilating-air through them to the wards, then pressure on the air in the basement chamber is necessary to lift and force the chilled and heavy air into the wards. For this purpose a disk fan 30* in diameter, run at and quiet speed, will supply all the air needed to twenty t> A hospital equipped for such cooling work mus( have, in ad- dition to the inlet windows for Use when heating is required, a separate window and >pei ial fan for dog day weather work. When either is "pen for action the other must be closed. The urfa< e foi air must be large, and pro] tioned to the difference in temperature between the • used for cooling and the temperature desired for the wards. When the mean temperature of water in the heater i and the temperature of the air before passing through the i oolers is o» . and after passing through 3 2 Air and the Hospital. square foot of the cooler will cool about three hundred and fifty cubic feet of air an hour through 15 . The method is practicable when an abundance of cold spring-water under natural flow can be had. Results are, however, likely to be disappointing because of the increased relative humidity attending the chilling of air when air-dry- ing does not follow its cooling. Into the large, interesting, but involved question of artificial cooling by mechanical refrigeration this paper cannot enter; time forbids it, and general utility does not invite us to such a discussion. V. A few points only can be noticed with reference to the warming of hospitals. Because hospital ventilation must be made free, the air-quantity necessarily used for that purpose is therefore abundant for conveying heat to wards and to other rooms by the indirect method of heating. If the air which ventilates the wards is also the vehicle for* the carriage of heat for their warming, then because the air-supply is large the temperature of the air entering rooms even in zero weather need be but little above the temperature of the rooms themselves. Low temperature of heated air insures an agree- able, if not a hygienic, quality of air, because not deteriorated by scorched dust and the odors and qualities peculiar to su- perheated air. When for any reason direct radiation must be used, — as is often the case, especially in rooms other than wards, — the radiators should be selected with due reference to plainness, smoothness, and accessibility to surface for cleaning. The temperature of the heating-surface, especially for gravity work, should be maintained at as low a point as is consistent with the proper warming of the hospital, and the heating- surface of the radiators should be correspondingly large. In case fan-power is used for moving and distributing the air, the rapid flow of air over the indirect heaters makes a higher temperature and a smaller area of those surfaces admissible ; because the rapidity of air-movement through the heater Woodbridge. 33 makes the contact of air and its dust contents too brief to admit of deleterious effects, unless the surface- are given a temperature abnormally high. For the purpo-<- of giving to heating-surfaces a mild rather than a high temperature, their heating can be most suitably done, and also their temperature most perfectly controlled, by using water rather than steam as a medium of transfer of heat from fires to radiators. The use of hot water is fur- ther to be recommended, if that water i> heated directly by fires, on the ground of economy in the use of fuel: first, be- cause of the transfer of a larger proportion of the heat-com- bustion to radiator- than when steam is employed; and sec- ond, because of the easier and more complete regulation of the building temperature, which make- less liable and un- necessary the overheating of rooms in mild weather, and the opening of window- for relief, and the large waste of heat attending that practice. Economy, therefore, favor- th< of water at both end- of a system — at the tire> and at the radiators. The first cost of a hot-water plant, for equal heating and ventilating work with steam, varies from thirty per cent to fifty per cenl more than the cost of a Steam apparatus. The saving in fuel by water-boiler heating has found by careful experiment to vary from fifteen per • i-nt to twenty per cent over the cost of doing the same work by steam. A possible further advantage in the use of water, and for the large ini rease of heating surface over that required when m is used, i- in the availability of that large surfao cooling work in the summer, already alluded to. In the matter of warming, as well a- of ventilation, tin operating room furnishes opportunity, if not special treatment. The eflfei 1 on the patient of tin ' posure of thilled window glass should be compensated bj irrespondingly heated surface for radiating to the ; a- much heat as the bod] 1 may be in pipe form, carried about the window frann Over (millions and other part- of the framework in a Rlfl to be neither < on. pi. UOUS nor light int. \\ h( I 34 Air and the Hospital. dows are double glazed, and with ample air-space between the plates, that space, and with it the inner glass, may be warmed by steam or hot water pipes concealed from view within the space. VI. Both time and subject limitations forbid any further gen- eral discussion of the many detailed applications of princi- ples to practice, or of the adaptation of systems to special cases. The most perfect hospital ward ventilation on this continent is found where the absence of a system is conspic- uous, and the use of a method is very much in evidence; where the mountain foot-hill is the site, and where wide open windows, night and day, through the stillness and the storm of weathers, make the indoors as much one with the outdoors as is possible; and where warming is thought of and provided for only when clothing for night or day is changed for its opposite. The question for such wards is not one of artificial ventilation, but of quick, effective, and least costly warming for the half-hour morning and evening change of dress. Shall that be by closed windows and great direct heaters placed within wards? Or shall it be by pow- erful indirect heaters and fans beneath the wards, capable of excessively free artificial ventilation while warming is be- ing effected, and while the clothing of beds and of persons is being shaken up or changed, and are giving off their microbic dust to air? Probably the method having the least system is the least costly in installation, and possibly in operation as well. Which method is the least and which is the most hygienic ? That is the paramount question for us, — the continuance or the discontinuance of ventilation for those one-half hour periods ? In the first place, the exposure to whatever menace there may be in closed windows, suspended ventilation, disturbed and floated germ dust, is of short duration, practically one twenty-fourth of the time of hospital habitation and treat- ment. In the second place, it is a well-known fact that the Woodbridge. 35 quantity of microbic dust within enclosures is inversely as the volume of air with which they are continuously ventilated; and, what is more to our purpose, tl it a temporary suspen- sion of ventilation, even in crowded rooms, does not result in markedly increasing the microbic population. Records show that the microbic proportion of one in rooms freely and continuously ventilated frequently becomes nine in sim- ilar rooms which are indifferently ventilated; and that the proportion of one holds for some time, with only slow cumu- lative change, measured by days, when the ventilation of the room is made indifferent, rather than energetic. In this fact Is evidence that the presence of parasitic dust in enclosures arises from its accumulation by slow aggregation within them, rather than from any temporary suspension or reduction of ventilation or the sorties of microbic battalions from the gar risons of infected furnishing, clothing, or person. The efficacy of activity in the movement of ventilating air to carry away, and to effectively dispose of, floating dust is plainly proved, as is also the importance of carrying ventila- tion to a point of effecting it by a method which shall insure the accomplishment of that important purp Probably the records of the Massachusetts Hospital for Consumptives will show thai the daily twenty three hours of cyclonic ventilation to which its wards are subjected makes abortive all sallies of mic robic pests during the- one hour per day of suspended ventilation. After .ill is said and done, the truth remains that perfeel ventilation is fir from insured by perfection of system. A perfeel system of ventilation is like a perfect human body. That body without life is a corpse. The system without per form.ini e is void. \ greal hospital what or where let US not name, lest we remember boasts of its fine ventilation. A \ i - i t to the bos pital, and a tour through its wank gave no evidence of that purity and quality of air which good ventilation should in sure. Quite to the contrary, the i onditions were notably bad. In response to b mild suggestion of surprised disappointment, the assuranc e was given, w ith a serene i omplai < m y, that the 36 Air and the Hospital. ventilation is superior, and, indeed, perfect; and an invita- tion was extended to inspect it, and to go to the engineering quarters in the basement for that purpose. Sure enough, there was found a fine equipment, — boilers, heaters, fans, engines, and piping to bewilderment, — and in charge a smiling engineer ready to assure all comers that his hospital was the best ventilated in the country, because he had an apparatus which, when run for one- half hour, finely flushed out the entire hospital — so finely, indeed, that one-half hour a day was found to be quite enough to provide good ventila- tion! Ability in repose was reckoned as equal to ability in action. A corpse revivable each day for one-half hour would be doubtfully received for domicile even by a hospital. VII. Temptations to discuss, or even to note, special methods of ventilation, and various methods of heating for meeting spe- cial requirements of the several types of hospitals, are re- ferred to the clock, and are denied by your patience. There- fore let the closing of our study bring us back to its beginning. The basal facts of the universe are two, energy and matter. Of those two, we are most sure that energy exists. Matter is evident to our senses only as it is the abode, the field of action, of energy. Energy is made manifest to us through our phys- ical senses only in and through matter. Our bodies are mat- ter; our lives are energy. Our bodies are as infinitesimal in the great aggregate of matter as are our lives an infinitesimal fragment of the infinite and eternal energy. The energy that is in our body, and that without our body, and at our con- venience and command, is under the direction of the intelli- gence and the will with which we are endowed as the off- spring of God, and through which we lay hold of that of Him and His within the reach of our taking, appropriating, and using. In the carbon of food which grows out of the earth, and in the oxygen of the air which inswathes the earth, are the tan- Woodbridge. 37 gible souk es of our vital energy. One is forthcoming through man's co-operative effort; the other, in immense store, is pro- vided and replenished without man's agency. Crudeness, coarseness, variableness, and taintedness, in quality or in serving, characterize man's productive work. Perfect] and completeness, invariableness and taintlessness, charac- terize that which is from the Giver of every good and perfect gift. So also, imperfection and impurity on the side of that which is produced through man's agency is not to his hurt, as is defect in that which God supplier Air must be pure. Food may be, had better be, but need not be, pure. Therefore, the question with man should be, What limita- tion must of necessity, for the protection and perfection of his life, be put on air-supply? and not. What i^ the least air- supply that is tolerable or requisite to the continuance of life? The question of vital economy is not, What least will keep the vital Same of life from extinction? but, What will hold it to it> fullest glow without flickering it, or extinguishing it, in drafts? Enfeebled vitality, the habitat of hospitals, is in a por- tion of corresponding sensitiveness and susceptibility to en ergy contributing or energy detracting environment. Whether, therefore, it be in the matter of food or of air, to the sick, above all others, energy restoratives should be furnished in the purest and the most life giving form. Pure air i> tantamount to abundance of air. It i^ the function of the trained engineer to furnish air volume to the maximum, and to reduce both of the restricting drafts to a minimum. It is the function of the hospital management to deal with the matter of proper balance between vital profits and bank drafts. 'I'Ik weights are, on the one side, the value of vital of life, either in mere existence or in varied di and intensity; and, on the other side, the value of the dollar. The divine revelation, the pulpit, the book and the platform of moral ethii S, the in-tim live value ea. h living on his lite, these are th< from width we learn the hi of the vital ein simple probl $8 Air and the Hospital. As to the other factor, the dollar cost of air, if one shaft of revealing light shall do anything to disclose and dislodge that sordid obstacle to the completeness of hospital service, the purpose and hope of this paper will be abundantly and thankfully realized. COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, f.s provided by the library rules or by special arrangement with the Librarian in charge. b