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Human-Environmental Interactions in Cities
Human-Environmental Interactions in Cities:
Challenges and Opportunities of Urban Land Use
Planning and Green Infrastructure
Edited by
Nadja Kabisch, Neele Larondelle,

Angela Reeve and Martina Artmann
Human-Environmental Interactions in Cities:
Challenges and Opportunities of Urban Land Use Planning and Green Infrastructure,
Edited by Nadja Kabisch, Neele Larondelle, Angela Reeve and Martina Artmann
This book first published 2014
Cambridge Scholars Publishing
12 Back Chapman Street, Newcastle upon Tyne, NE6 2XX, UK
British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library
Copyright © 2014 by Nadja Kabisch, Neele Larondelle, Angela Reeve,

Martina Artmann and contributors
All rights for this book reserved. No part of this book may be reproduced, stored in a retrieval system,
or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, without the prior permission of the copyright owner.
ISBN (10): 1-4438-5895-1, ISBN (13): 978-1-4438-5895-3

TABLE OF CONTENTS
Foreword ................................................................................................... vii
Introduction ................................................................................................. 1
Nadja Kabisch, Neele Larondelle, Angela Reeve and Martina Artmann
Part One: Urban Land Use Conflicts and Green Infrastructure
Chapter One ............................................................................................... 12

Engaging Decision Makers in the Business Case for Biophilic Urbanism
Omniya el-Baghdadi, Cheryl Desha and Charlie Hargroves
Chapter Two .............................................................................................. 27

Considering Research Enquiry into Biophilic Urbanism and Office
Worker Productivity
Angela Reeve, Cheryl Desha, Caroline Kramer, Charlie Hargroves
and Peter Newman
Chapter Three ............................................................................................ 47

Premises for the Developmental Principles of Green Infrastructure,
a Case Study: Lodz City, Poland
Andrzej DáugoĔski
Chapter Four .............................................................................................. 66

Urban Ecosystem Services in Berlin, Germany and Salzburg,
Austria: Climate Regulation and Recreation Function
Nadja Kabisch, Neele Larondelle and Martina Artmann
Part Two: Human-Species Interactions: Challenges on Biodiversity

in Cities
Chapter Five .............................................................................................. 82

The Urban Garden: A Centre of Interactions between People
and Biodiversity
Sonja Knapp
vi Table of Contents
Chapter Six .............................................................................................. 100

Supporting Awareness of Urban Biodiversity: School Garden,
Schoolyard and School Surrounding
Karlheinz Köhler and Dorothee Benkowitz
Chapter Seven.......................................................................................... 115

Allergenic Potential of Street Trees in Boston, Massachusetts
Eric Arnold, Michael W. Strohbach and Paige S. Warren
Chapter Eight ........................................................................................... 142

Correlation between Environmental Traits and Physiological State
of the House Sparrow (Passer domesticus L.) as a Model of Urban
Species
Javier Pineda, Amparo Herrera, Pablo Salmon, Maria Teresa Antonio
and Jose Ignacio Aguirre
Contributors ............................................................................................. 158
Index ........................................................................................................ 163

FOREWORD
DAGMAR HAASE, SALMAN QURESHI

AND JÜRGEN BREUSTE
Cities are complex adaptive systems embedded within even more

complex and adaptive ecosystems. Cities and their regions are hubs for
people, infrastructure and commerce, requiring extensive resources and
putting intense pressure on the environment. Urban landscapes are the
everyday environment of the majority of the global population, including
four out of five Europeans, every second Asian and almost all Latin
Americans. The continuous increase in the number and size of cities and
the permanent consumption of virgin land into sealed surface pose
significant challenges for reducing the rate of biodiversity loss and related
ecosystem functionality and ensuring human welfare, which is of major
importance in cities. Plants, animals, and microorganisms are the base of
all ecosystems and the services they provide. However, urban areas also
provide a range of benefits to sustain and improve human livelihood and
the quality of life through urban ecosystems.
Generally speaking, locally generated ecosystem services have
substantial impacts on the quality of life in urban areas and should,
therefore, be more explicitly addressed in conceiving strategies aimed at
sustainable development, liveability and resilience in urban milieu. From
the Millennium Ecosystem Assessment we know that sixty per cent of the
global ecosystem services are degraded or used unsustainably, having
adverse effects on human well-being. Because almost no ecosystems
remain unimpacted by humans and humans cannot exist without
ecosystems, protection and sustainable use of ecosystems are no longer an
isolated interest but a key component of global sustainable development,
particularly in cities.
Urban biodiversity contributes to multiple ecosystem functions and
services that are very important for the well-being of urban residents:
reductions in local air pollution, reductions in the urban heat island effect,
direct health benefits, such as a lower prevalence of early childhood
asthma, reduced mortality, and general health improvements enhanced
viii Foreword
public ecological knowledge and awareness of sustainability challenges.

Such ecosystem services are generated by a diverse set of urban land uses,
including parks, cemeteries, golf courses, watercourses, avenues, gardens
and yards, verges, commons, green roofs and facades, sports fields, vacant
lots, industrial sites and landfills. Thus, the management of urban
ecosystems must be connected to the social-ecological dynamics of
developed land. Furthermore, the dependence of cities on surrounding
landscape and its biodiversity as well as ongoing interactions between
processes occurring in urban, peri-urban and rural contexts are essential
for sustaining the production, enhancement and maintenance of ecosystem
services and overall urban resilience. To address these challenges of
ecosystem degradation and maintenance in cities an interdisciplinary
social-ecological system approach is critically important and needed at this
time.
INTRODUCTION
NADJA KABISCH,
INSTITUTE OF GEOGRAPHY, HUMBOLDT-UNIVERSITY
BERLIN, GERMANY
DEPARTMENT OF URBAN AND ENVIRONMENTAL SOCIOLOGY,
HELMHOLTZ CENTRE FOR ENVIRONMENTAL RESEARCH – UFZ
LEIPZIG, GERMANY
NEELE LARONDELLE,
INSTITUTE OF GEOGRAPHY, HUMBOLDT-UNIVERSITY
BERLIN, GERMANY
ANGELA REEVE
QUEENSLAND UNIVERSITY OF TECHNOLOGY, BRISBANE,
AUSTRALIA
AND MARTINA ARTMANN
DEPARTMENT GEOGRAPHY AND GEOLOGY, UNIVERSITY
OF SALZBURG, AUSTRIA
Background
Over the last decade, there has been a surge in research on urbanisation
processes, with many scientific studies in the field of urban ecology
considering the relationship between these trends and biodiversity and
ecosystem services (Konijnendijk et al. 2013). Urbanisation, as a
phenomenon describing the relative increase of population in cities and
urban areas compared to a relative decrease of the rural population (United
Nations 2012), is one of the main driving forces influencing the quality of
urban life, the way in which biodiversity is present in the urban
environment and, the quality and quantity of ecosystem services.
This has become particularly pertinent since 2008, when the United
Nations announced that over half of the world´s population was living in
cities. Since that time, numerous studies have focused on the human-
2 Introduction
environment interactions in cities. Within this context, the term “urban

ecosystem services” became increasingly used in scientific literature.
Urban ecosystem services are described as the benefits residents in cities
obtain from the ecosystems in cities (Cork 2001; Elmqvist et al. 2013;
Millenium Ecosystem Assessment 2005). Studies particularly deal with
the specific characteristics of urban green spaces that are beneficial for the
urban environment, such as by regulating the urban climate through
temperature reductions (Lafortezza et al. 2009; Spronken-Smith and Oke
1998; Yu and Hien 2006) or air purification (Jim and Chen 2008;
Strohbach and Haase 2012; Escobedo and Nowak 2009). Interdisciplinary
studies combining ecological and social science methods refer to mental
and physical improvements of the urban population through cultural
services of urban green spaces. That could be the provision of spaces for
recreation and social interaction (Kabisch and Haase 2014; Smith,
Nelischer and Perkins 1997) or the experiential learning about the natural
environment (Irvine et al. 2013; Joh, Nguyen and Boarnet 2011; McMillan
2007). Further, a number of studies showed a measurable, positive
psychological health effect when urban residents have contact with nature
(Völker and Kistemann 2013), particularly with high levels of biodiversity
(Dallimer et al. 2012; Fuller et al. 2007). Such research has demonstrated
that successful urban green space planning could contribute to human
well-being while promoting biodiversity conservation.
Land use demands and conventional patterns of urban development
threaten urban green space and biodiversity, however. Studies show that
green areas are now on average smaller than they have been previously in
most cities worldwide, with fewer overall hectares per capita (Artmann
2013; Breuste, Haase and Elmqvist 2013). This is also shown by an
overall increase in soil sealing, which demonstrates the degree to which
landscape ecological knowledge is not being translated into practice
(Breuste 2010).
To significantly analyse the patterns of human-environmental
interactions within the complex city environment, methodological
approaches need to be adapted to local conditions. Although studies using
generalised approaches and data can provide some guidance to city
planning, these do not account for the degree to which local contextual
factors define urban ecosystem development and modification, nor the
way in which urban populations depend on these ecosystems. Indicator-
based urban socio-ecological modelling is one way in which specific local
interactions could be analysed and transferred to other spaces. Other
methodological innovations include various approaches such as statistical
modelling, pattern analysis or GIS-research (Kabisch and Haase 2014).
Human-Environmental Interactions in Cities 3
Further, the combination of qualitative or quantitative research combining,

such as focus groups, observation, and interviews with questionnaire
surveys and statistical analysis are encouraging for future urban ecosystem
research.
Recent studies on monetary (Gómez-Baggethun and Barton 2013) and
non-monetary assessment of ecosystem services (Daily et al. 2009) seem
to approach promising scientific tools to support urban planning and
policy decision making. These tools attempt to demonstrate and link
economic, social, and ecological benefits provided by the urban
ecosystem. However, the need for further research to provide planning and
policy with standardised temporarily and spatially explicit methods and
indicators remains. These methods should be practical, applicable, and
should allow for a flexible selection process, which is at best consistent,
comprehensive, credible, and sensitive to changes in land management
(Oudenhovena et al. 2012).
Scope of the Book

The book Human-Environmental Interactions in Cities – Challenges
and Opportunities of Urban Land Use Planning and Green Infrastructure
provides a number of papers of current research in urban ecology and is in
direct accordance with the mission of the Society of Urban Ecology
(SURE). SURE was established in 2009 to develop knowledge in
understanding the structure and function of urban ecosystems, to facilitate
international collaboration and to enrich the dialogue between researchers
and practitioners. The main aim of the SURE is to contribute to a balanced
interaction between humans and their environments in cities and towns
worldwide.
The book addresses international research communities concerned with
conceptual, scientific, and design approaches to urban land developments
and biodiversity. The main focus is on the understanding of human-
environment interactions analysed by multi-disciplinary approaches. The
book includes papers on new concepts and challenges emerging from
pressure caused by urbanisation—that is the need for sustainable green
space development from a patch to a city wide scale. In addition, the book
shows important human-species interactions in an increasingly urbanised
world. Case studies refer to current challenges for biodiversity in urban
areas. In particular, anthropogenic influences on the survival or local
extinction of species—such as the structure of the built environment, and
emission of pollutants—are identified. In all cases, the importance of
urban planning on green infrastructure development, biodiversity
4 Introduction
conservation and management within the urban ecosystem is highlighted

and planning recommendations are given.
To focus on relevant and up-to-date topics, the contributions to this
book relate to the following essential main fields of research in urban
ecology:
1. Theory of urban ecology

2. Multifunctional green infrastructure
3. Socio-ecological complexity of urban areas
4. Urban biodiversity and municipal governance
These topics were intensively discussed at the 1st Congress of the

Society for Urban Ecology (SURE) which was organised by the
Landscape Ecology Lab of the Humboldt-University in Berlin, Germany.
The congress took place from 25-27 July 2013. About 210 participants
representing more than 30 countries enumerated and validated the
discipline’s growing concerns by showcasing 190 papers of concurrent
scientific and social science research from different contexts around the
world. The large number of presented papers and the even higher number
of submitted proposals—around 300 abstracts for proposed papers and
posters—proved the high research relevance of the presented topics.
In conclusion, this book contributes to an increased understanding of
how urban ecosystems function, provide goods and services for urban
residents, how they change and what allows and limits their performance,
and how governance in general can contribute to and use this
understanding for a successful urban planning in an ever more human-
dominated world. To further understand this complexity, new approaches
in urban planning could be linked with research and education to
encourage young researchers to deal with emerging topics, innovative
methods and newly developed theories. This book presents a first step by
combining empirical case studies with new theoretical insights. These
insights are analysed through emerging methodological combinations, and
are presented by young scientists in early academic careers.
The Nature of the Papers

The eight papers presented in this book include theoretical-conceptual
texts but also contributions that use a theoretical background to introduce
empirical case studies. The papers refer to a variety of conceptual and
geographical scales ranging from regional to local scales. Some studies
focus on a specific case study which has been investigated in detail.
Nevertheless, the results can in terms of applied methodological

approaches, concrete insights or recommendations to some extend be
transferred to and used for other comparable cases.
With regard to their disciplinary origin and scientific background, the
papers come from the fields of landscape ecology, urban ecology, biology
and human geography. Pilot studies as well as disciplinary papers by PhD
students and post-doctoral researchers rooted in landscape ecology are
shown. They describe theoretical approaches, research questions and
methodological issues related to their scientific work in progress. Further,
a general overview of research and literature related to a specific research
problem is presented.
Structure and Contents of the Book

This book consists of two parts.
Part 1: Urban land use conflicts and green infrastructure

The first part about urban land use conflicts and green infrastructure
includes four papers dealing with the concept of biophilic urbanism and
the provision of multifunctional green infrastructure in specific cases.
Omniya el-Baghdadi et al. introduces biophilic urbanism as an urban
design concept that focuses on the integration of natural elements as
features in urban landscapes. They review some cases where biophilic
elements are used in different geographic scales, from urban parks and
green streets at the city and neighbourhood levels to as concentrated as
green walls and pot plants at the level of buildings. They further highlight
emerging gaps in economic knowledge of using biophilic elements in
landscape planning. Referencing previous work in the field, she suggests
opportunities for engaging decision makers in the business case for
biophilic urbanism. The concept of biophilic urbanism was also used by
Angela Reeve et al. They refer to the specific level of buildings and
explores how nature inside buildings (such as pot plants and internal green
walls) can increase worker productivity in office buildings. Drawing on
insights from existing research in this field and from a summary of a
survey within a Perth office building, the paper makes recommendations
regarding opportunities for focusing future investigations to enhance
understanding of how biophilic urbanism can contribute to increased
wellbeing and productivity in office buildings. In a detailed case study
Andrzej DáugoĔski introduces a method for analysing the morphological
structure of the total green infrastructure in the Polish city of àódz. He
6 Introduction
determines the city’s green infrastructure properties and identifies the

development principles of the city’s green infrastructure. Finally, specific
development scenarios for àódz’ green infrastructure are developed and
assessed. The identified green infrastructure and the scenarios underline the
complexity and functional diversity of the cities different green
infrastructure types. Finally, Nadja Kabisch et al. introduce findings from
an EU-BiodivERsA research projected on urban ecosystem services and
biodiversity (URBES). The authors show how regulating and cultural
ecosystem services are provided by urban green and blue spaces in the
cities of Berlin, Germany and Salzburg, Austria. They conclude that the
methodological approach combined with the findings from the ecosystem
service assessment could be used as important contribution in urban green
space and residential land use planning.
Part 2: Human-Species Interactions: Challenges on Biodiversity

in Cities
In the second part on human-species interactions, the book shows
challenges on biodiversity in an increasingly urbanised world. In a first
paper, Sonja Knapp presents a review that summarises positive and
negative effects of urban gardening on biodiversity. She concludes that
urban gardens are not only centres of interactions between people and
biodiversity but simultaneously contribute to human well-being and
environmental education while management and human preferences can
shape species assemblages. In order to highlight the importance of
schoolyards as learning environments and the effects of school gardening
on the pupil’s perception of plants, Karlheinz Köhler and Dorothee
Benkowitz outline the recent situation of school gardens in Baden-
Württemberg, Germany. By presenting some interesting case studies, the
authors stress the multitude of opportunities for children to get in touch
with nature, while these opportunities are often underestimated in their
educational impact. In contrast to papers highlighting benefits urban
ecosystems provide for city residents, Eric Arnold et al. refer to nuisances
and disservices by urban ecosystems. In particular, the authors analyse the
release of pollen with allergenic relevance into the ambient air by urban
street trees in the city of Boston, U.S. They conclude that allergenic
potential should be taken into consideration when planting trees in cities.
This section concludes with the work of Javier Pineda et al., who analyse
the effects of land uses and air pollution on populations of House Sparrow
as a model of urban species. Applying different urban models following a
gradient from a small village to a big city in Spain shows, that intensive or
quick modifications in urban areas could increase selective pressure and

negatively affect populations of well adapted organisms. Moreover, this
paper adds significant novelty through the use of a relatively unique
bioindicator for urban ecosystem research.
Concluding remarks
The range of papers presented in this book showcase a variety of
disciplinary, methodological and geographical perspectives, reflecting the
diversity and complexity of human-environmental interactions in a rapidly
urbanising world. The analysis of these interactions and the developments
and changes of urban habitats for species aims at the assessment of current
challenges of urban ecosystems. Current and future SURE activities will
certainly be devoted to these challenges.
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8 Introduction
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PART ONE
URBAN LAND USE CONFLICTS

AND GREEN INFRASTRUCTURE
CHAPTER ONE
ENGAGING DECISION MAKERS

IN THE BUSINESS CASE FOR BIOPHILIC
URBANISM
OMNIYA EL-BAGHDADI, CHERYL DESHA

AUSTRALIA
AND CHARLIE HARGROVES
AUSTRALIA
CURTIN UNIVERSITY SUSTAINABILITY POLICY INSTITUTE,
PERTH, AUSTRALIA
Abstract
The cognitive benefits of biophilia have been studied quite extensively,
dating as far back as the 1980s, while studies into economic benefits are
still in their infancy. Recent research has attempted to quantify a number
of economic returns on biophilic elements; however knowledge in this
field is still ad hoc and highly variable. Many studies acknowledge
difficulties in discerning information such as certain social and aesthetic
benefits. While conceptual understanding of the physiological and
psychological effects of exposure to nature is widely recognised and
understood, this has not yet been systematically translated into monetary
terms. It is clear from the literature that further research is needed to both
obtain data on the economics of biophilic urbanism, and to create the
business case for biophilic urbanism. With this in mind, this paper will
briefly highlight biophilic urbanism referencing previous work in the field.
It will then explore a number of emergent gaps in the measurable
economic understanding of these elements and suggest opportunities for
engaging decision makers in the business case for biophilic urbanism. The
Engaging Decision Makers in the Business Case for Biophilic Urbanism 13
paper concludes with recommendations for moving forward through

targeted research and economic analysis.
Introduction
Internationally, the concept of ‘biophilic urbanism’, a term coined by
Professor Tim Beatley to refer to the use of natural elements as design
features in urban landscapes, is emerging as a key component in
addressing climate change challenges in rapidly growing urban contexts
(Beatley 2010). Achieving biophilic urbanism in urban environments is
facilitated through the use of ‘biophilic elements’; i.e. functional design
features (Beatley 2010). These elements can occur at three geographic
scales, from as extensive as urban parks and green streets at the city and
neighbourhood levels to as concentrated as green walls and pot plants at
the level of buildings (SBEnrc 2012). Each of the biophilic elements has a
few specific benefits, while a few other benefits are shared by all. Table 1-
1 summarises the benefits of a range of biophilic elements, with many
shared by all (SBEnrc 2012).
Studies suggest that a wide range of health benefits may arise from
daily views of nature (Beauchemin and Hays 1996; Benedetti et al. 2001;
Elzayadi 2011; Marcus and Marni 1995). The seminal work of Roger
Ulrich in 1984, which found faster rates of recovery in hospital patients
with views of nature compared to those without, laid a strong empirical
base for this research (Ulrich 1984). More recently, a 2012 report by
Terrapin Bright Green discussed how such benefits of nature might affect
building occupants, considering in particular employees in the workplace
(Terrapin Bright Green 2012). Their report discussed benefits of biophilia
in reducing stress, anxiety and absenteeism as well as enhancing
productivity and overall employee well-being. These studies, however,
still lack economic rigour.
Reviewing this emerging field, it is evident that economic understanding
of biophilic elements and their interaction with the built environment
remains limited. Within this context, this paper will discuss a number of
gaps in economic data. In considering how to articulate the economics of
biophilic urbanism, as the current understanding is ineffective, this paper
also highlights a gap in understanding what decision makers need in order
to make investment decisions regarding the use of biophilic elements.
Drawing on existing literature, as well as six case studies developed by the
authors and two stakeholder engagement workshops conducted in 2011 for
the Sustainable Built Environment National Research Centre (SBEnrc;
SBEnrc Stakeholder Workshop 2011), the authors discuss emergent needs
14 Chapter One
and suggest opportunities of decision makers. The paper concludes with

recommendations on areas for future research to enhance understanding of
the economics of biophilic urbanism. This investigation has been
undertaken in collaboration with SBEnrc, and seeks to compliment and
extend the work of Biophilic Urbanism expert Tim Beatley (2010).
Table 1-1. Overview of the elements of Biophilic Urbanism.

Element Forms Specific Benefits Common Benefits
Ǧ Pot plants in buildings Ǧ Reduces building

Indoor Revitalises urban
Ǧ Indoor living walls, including pots within a occupant illness
Plants environments
frame (also see Green Walls) Ǧ Increases building
Ǧ Indoor planted vegetation, such as atriums occupant productivity
and large planted installations Ǧ Improves air quality
Reduces urban heat island
Ǧ ‘Intensive’: Soil deeper than 200mm and Ǧ Improves building effect
Building
Green vegetation up to the size of trees energy efficiency

Roofs
Ǧ ‘Extensive’: Soil up to 200mm with ground Ǧ Water management
cover vegetation Ǧ Space efficiency Improves air quality
Ǧ Food production
Ǧ Internal and external green walls Ǧ Sound insulation
Green
Ǧ Include: vegetation directly attached to Ǧ Increases roof/wall
Walls Improves microclimate
infrastructure (such as ivy), panel systems lifespan
with substrate (such as preplanted panels Ǧ Vertical urban
with soil), and container or trellis systems. farming
Sequesters carbon/ reduces
Ǧ Street trees and canopies Ǧ Encourages walking, greenhouse gas emissions
Green
Ǧ Shade planting for buildings and cycling
Verges
Ǧ Green streets and alleys that create cool Ǧ Reduces building
pervious greenways cooling/ heating Increases biodiversity
Ǧ Rain gardens and bio-swales integrated into energy use
Neighbourhood
stormwater management plan and Ǧ Water management

consisting of pervious channels Ǧ Food production Improves water cycle
Ǧ Green permeable sidewalks management
Ǧ Urban parks and gardens placed close to Ǧ Encourages walking

Green transportation routes and cycling
Islands Provides amenity
Ǧ Community farms close to homes Ǧ Food production
Ǧ Residential backyards Ǧ Increases community
Ǧ Lawns and gardens (public and private) cohesion Enhances well-being/ reduces
stress
Ǧ Green corridors (biodiversity corridors) Ǧ Links biophilic
Green reaching outside the urban area elements with each
Corridors Recreation
Ǧ Highway crossings and migratory routes other
Ǧ Backyard commons Ǧ Encourages walking
Ǧ Vegetated buffer zones along coastal areas and cycling
Reconnects with nature
Ǧ Large scale community gardens and urban Ǧ Food production

Urban
City
farms Ǧ Employment and Revitalises cities

Farming
Ǧ Urban and peri-urban agriculture education
Ǧ Wetlands (natural and constructed) Ǧ Water management,

Waterways, Increases property value
Ǧ Ponds and lakes treatment and storage
and water
Ǧ Rivers and streams Ǧ Protects downstream
sensitive
Ǧ Vegetated swales, drainage corridors, water bodies
urban design infiltration basins, etc. Enhances tourism
features
Ǧ Oceans and associated coastal vegetation
Methods
According to Kaplan and Duchon (1988), the use of multiple methods
allows for cross-validation, or triangulation, of findings from different
sources and data; enhancing the robustness of findings. For this reason,
this paper draws from three different qualitative interpretations and
analyses—literature review, case studies and workshops. These methods
are described in the following paragraphs.
The literature review method was used to provide background context
of the available information on biophilic urbanism and economics (what is
so?). This is due to researcher’s assumption that knowledge accumulates
and that future research can build on what has been done previously. This
sheds light on what the missing gaps in the literature are (what is
missing?). Once the existing literature and gaps have been identified using
this qualitative technique, an integrative literature review followed, which
involved drawing on the existing context to distil insights to provide the
literature review with an added depth that is informative and relevant.
These emerging insights dictated the subsequent method, case study
exploration, which aimed to dig deeper into the enquiry (what is the key
question?). Six case studies (Berlin, Singapore, Chicago, Toronto
Brisbane and Portland), were selected based on research conducted by the
broader research project for the Sustainable Built Environment national
research centre, which identified the successful mainstreaming of biophilic
elements within these cities (SBEnrc 2012). A number of economic
analysis related questions ensured consistent evaluation of all case studies,
providing insights that can inform future use of biophilic elements. The
sample for the literature review and case studies included journal articles,
books, industry and government reports and online pages.
Semi-structured interviews with two to three participants, identified
from the case study exploration based on their involvement in application
of biophilic elements in their respective city, were then conducted.
Questions or key topic areas from the case study exploration emerged.
These were asked or discussed to provide comprehension or validation of
findings from the literature review and case studies. The use of semi-
structured interviews allowed the interviewer to enquire more deeply into
topics of particular interest that emerged during each interview. To
enhance the validity of the interview process, the responses given by
interviewees were summarised and repeated back to the interviewee to
confirm that the information has been interpreted correctly and to allow
room for further clarification if necessary.
16 Chapter One
The paper also draws from two stakeholder workshops for SBEnrc
involving over 25 participants in Perth and Brisbane. The workshops were
based on the methodology of ‘Collective Social Learning’, created by
Emeritus Professor Valerie Brown, to guide participants through a process
to consider first their vision for a biophilic city and the aspects that enable
and disable achieving such vision. Following this, a brainstorm was
undertaken with each workshop group, to inform the research team’s
consideration of the various elements of an economic consideration of
both direct and in-direct economic benefits and costs of the use of
biophilic elements in cities and other urban areas.
Emergent gaps in economic understanding

As the use of biophilic elements begins to gain momentum in some
cities, it is evident that some governments and councils have started to
recognise the positive potential a biophilic building, neighbourhood or city
has to offer. Though, with apparent economic ambiguity and uncertainty
of the value of environmental resources (Adamowicz and Beckley 1998;
ICEM 2003; Lintott 1996; O’Neil 1997), it remains a hurdle to completely
mainstream biophilic urbanism. The case studies have highlighted emergent
gaps regarding the economic inquiry of biophilic urbanism and a significant
need to further the current level of understanding. The following section
will highlight these gaps in knowledge that are essential in strengthening
the business case for biophilic urbanism. This includes: the quantification
and recognition of indirect benefits, understanding the application of the
multiplier effect to biophilic urbanism and identifying and implementing
mechanisms to address split incentives.
Indirect benefits
Unquantifiable benefits: Whilst some benefits, such as stormwater
management and energy savings, are easily quantified, others are not.
Social and aesthetic benefits have been notoriously difficult to translate
into monetary terms. Such benefits include education, community
connectivity, happiness, improved health and well-being, among others
that may not yet be recognised (Terrapin Bright Green 2012). Whilst these
benefits’ financial returns may not be easily recognised, at times they can
be the most significant (Alex Versluis, pers. comm.). This was most
evident in a green roof project on a YMCA building in Toronto, Canada,
where community involvement instigated a series of ongoing benefits
(City of Toronto 2011). Some of the benefits included revitalising an
undeveloped part of downtown Toronto and energising the community to

come together and work on a project as well providing a space to conduct
yoga and educational workshops. However, whilst these benefits are now
apparent in retrospect, it has still not been possible to quantify these in a
way that might inform the development of a business case for other
building owners similarly considering the installation of a green roof.
Contributing factors: Independent studies from some of the case
studies have attempted to quantify economic, social and environmental
benefits of biophilic elements but have acknowledged the difficulty in
capturing the full suite of benefits (Banting et al. 2005; Chicago Loop
Alliance 2011; Skyrise Greenery n.d; Sustainable Technologies 2005).
Measurable benefits such as stormwater management and energy savings
were generally easily quantifiable, as were some indirect benefits including
increased tourism and real estate value (Emily Hauth, Linda Dobson and
Matt Burlin, pers. comm.; Hitesh Doshi, pers. comm.). Yet, with regards
to these indirect benefits, uncertainty existed in pinpointing the precise
portion of the increase that is directly attributable to the biophilic element.
This is due to contributing factors such as refurbishments in the case of
real estate and advertisement, and weather in the case of tourism that also
play a role in increased value.
Multiplier Effect
In the case studies, biophilic elements were initially used to address a
particularly prominent challenge(s) facing the city. Once added to a
building, neighbourhood or city and when explored further, these biophilic
elements appeared to also positively reduce other negative externalities.
This suggests that biophilic elements provide positive multiplier effects,
however these are as yet only quantified and explored to a limited degree.
For instance, the serious problems of stormwater runoff in Portland
and the rising costs of traditional facilities was the first trigger for
alternative solutions. Portland city determined that the overall costs of
stormwater management could be reduced through the addition of green
infrastructure to stormwater management plans (ENTRIX 2010). These
green infrastructures, or biophilic elements, are now being retrofitted
throughout Portland under the Grey to Green (G2G) initiative, and include
green roofs, green urban space and Green Streets (among others). The city
of Portland has subsequently explored the broader benefits in terms of
health, well-being and liveability. The results indicated positive impacts
on physical and mental health, property value and crime rates (among
other, ENTRIX 2010). In a similar context, the rising issues of urban heat
18 Chapter One
island effect in Singapore prompted the need to rethink current urban

design. Exploring other benefits that emerged from biophilic elements, it
was clear that these elements financially assisted with stormwater
management and air pollution reduction. This financial impact of air
pollution was quantified in a Singaporean study (Quah and Boon 2003).
The study looked at the mortality and morbidity effects of particulate air
pollution on residents. By studying the statistical lives that could be saved
and the cost of illness incurred, the results showed that the total economic
cost of particulate air pollution in Singapore is US$3662 million (or about
4.31% of Singapore’s GDP in 1999).1 This demonstrates that the benefits
of urban nature went beyond targeting the initial externality, urban heat
island effect.
Crucial insights emerge in terms of managing these costly externalities
through the use of biophilic elements, creating significant economic gains
for Portland and Singapore. What these examples highlight is the need to
explore the extent of influence of biophilic elements across society; in
other words the multiplier effect. This multiplier effect of biophilia is a
topic that has not been yet been explicitly discussed in the literature.
According to Glaeser, Sacerdore and Scheinkman (2003), the presence of
positive impacts creates a ‘social multiplier’ where summative coefficients
exceed that of individual coefficients. Further research into exploring the
web of benefits from a biophilic element across society could add
significant value to demonstrate the monetary potential. The report by
Terrapin Bright Green (2012) has instigated a similar conversation with its
exploration of benefits on productivity across five sectors of the economy.
Their research explored benefits such as illness, absenteeism, staff
retention, job performance, healing rates, classroom learning rates, retail
sales and violence statistics. What this report has highlighted is the need to
continue to explore the multiplier effect of biophilic urbanism as there
could be other unidentified benefits. Identifying the extent to which
benefits of biophilic elements reach, coupled with metrics to measure their
positive impact, begins to demonstrate the remarkable gains that
companies and institutions can capitalise on.
Split Incentives
Whilst identifying the positive multiplier effect could strengthen the
business case for biophilic urbanism in cities, the issue of ‘split incentives’
may make it unfavourable for an investor. This is because the investor in a
1
The authors of this study note that due to some research limitations, the findings
from this study should be treated as indicative rather than conclusive.
biophilic element may not necessarily directly reap the benefits. Hence,
this potentially impedes financial returns that reduce the attractiveness for
private property owners (SBEnrc Stakeholder Workshop 2011). For
instance, a green roof retrofitted by a building owner will not necessarily
enjoy the full suite of benefits this provides, as building occupants within
proximity enjoy views of this rooftop and incur benefits such as stress
relief, and enhanced productivity, among others. Recognising and
exploring this limitation could help minimise this barrier by identifying
opportunities to link back the benefits to an investor.
Summary of gaps in economic understanding

A summary of the emergent economic gaps discussed above have been
captured in Table 1-2. It highlights the need to further explore these gaps
in order to strengthen the business case of biophilic urbanism.
Table 1-2. Emergent gaps in economic understanding of biophilic

urbanism.
Emergent
Opportunity in addressing gap
gaps
Indirect Opportunity to pinpoint the precise portion of the benefit increase

benefits that is directly attributable to the biophilic element.
Opportunity to identify and translate social and aesthetic benefits
into monetary terms. Such benefits include education, community
connectivity, happiness, improved health and well-being, among
others that may not yet be recognised.
Multiplier Opportunity to identify the extent of and long-term impact of a

effect biophilic element across society over time. Presentation of a web
of interrelated links could add significant value and facilitate
visual comprehension.
Split Opportunity to help minimise the split incentive issue. An investor

incentive in a biophilic may not necessarily directly reap the benefits, hence
impeding financial returns and reducing the attractiveness for
private property owners.
Engaging decision makers

One study distinguishes the difference between stakeholders and
decision makers by defining stakeholders as the players involved in the
20 Chapter One
process where their preferences are captured throughout. Likewise,

decision makers are players that are involved in the process but also
combine their judgments with the outcomes from the research project to
make the final decision (Hajkowicz 2008). The two workshops conducted
in Perth and Brisbane in 2011 by the research team from SBEnrc
highlighted the need to present a business case for biophilic urbanism in a
language that is targeted to suit decision makers. This should be based on
decision makers’ priorities and terminologies. Hence, in addition to the
emergent gaps in economic understanding of biophilic urbanism discussed
in the previous section, another prominent shortcoming of the business
case is recognising the role of decision makers in biophilic urbanism and
their emerging priorities. The following section will explore identified
priorities, which includes political priorities, ‘what’s so’ in existing
research, ‘what can be’ by distilling local data and future opportunities that
are not yet known. These key interventions highlight the need for further
research.
Government incentives
Results from the two stakeholder engagements revealed that financial
incentives are a crucial avenue to push the biophilic urbanism agenda
forward. This was reiterated in the case study findings. Brisbane
government, for instance, has introduced the ‘Green Door’ mechanism,
which will accelerate decisions for development proposals that are
identified to be among the most sustainable in Queensland (DLGP 2011).
This Green Door “fast track” incentive is designed to encourage
sustainable development by expediting applications through the often long
and complex development assessment system. As sustainable designs
occasionally incur high initial costs, particularly given the lack of
economies of scales in the green feature industry, motivation was required
to engage community members.
Financial incentives were identified as crucial for property owners. The
high initial cost of a biophilic feature as well as the split incentive issue
discussed earlier can impede their uptake. Hence, the limited benefits to
the building owner for green roofs and green walls may not be sufficient
for them to do this on their own accord. Discounted incentive was also
found in some of the cities explored. Most North American cities charge
property owners separately for stormwater runoff, enabling them to then
receive a discount where stormwater was managed onsite, principally
through the use of biophilic elements (ENTRIX 2010; Sustainable
Technologies 2005). These schemes raise awareness about the costs of
stormwater management, engage property owners and clearly demonstrate

the potential of a biophilic element.
These will all require government leadership to drive policies that are
adaptive and supportive of biophilic urbanism. In virtually all the case
studies explore, there was a political champion that drove the urban
greening agenda. This catalysed and encouraged the process.
What’s so
The two workshops also highlighted a priority for decision makers to
comprehend the current understanding or ‘what’s so’ of biophilic
urbanism. Capturing what is already known in the literature or what can be
learned from others was expressed as imperative. Learning from others
illustrates lessons in terms of successful application as well as highlighting
errors that can be avoided. These also outline the benefits experienced
from their application. These known benefits include: reducing energy
consumption, reducing heat island effects (such as reducing urban heating
from concrete and pavements open to solar radiation that will heat
buildings and vehicles), enhancing urban biodiversity that may provide
greater tourist attraction and greater levels of well-being, improving
resilience to natural disasters and extreme weather conditions, improved
health and healing outcomes, improving the experience of those visiting
and working in urban areas and public buildings, providing learning
opportunities in terms of local flora and fauna and responding to pressures
related to densification and revitalisation of cities (SBEnrc 2012). Hence
an opportunity arises in exploring examples from around the world,
conduct feasibility tests to present economic, environmental and social
benefits.
What can be
New wealth of opportunities highlighting what is possible with
biophilic urbanism was also distinguished as a priority in the SBEnrc
workshops. This can be in the form of a local demonstration project with
the findings presenting accurate and appropriate data in terms of the
environmental, social and economic benefits. A political champion is also
important to encourage demonstration projects. This was apparent in
Chicago and Portland where costs and benefits of the natural installation
were communicated effectively to the public through demonstration projects
(Chicago Loop Alliance 2011; ESTRIX 2010). These demonstration
22 Chapter One
projects were publicly accessible; hence the public could directly appreciate
the benefits.
Retrofitting schools with a green roof or green wall was expressed as a
beneficial case study as it has the potential to provide dual purposes of
being a case study and an educational facility. The results not only shed
light on the quantitative benefits, but also on aesthetic and social benefits
such as community connectivity, education, enhanced productivity
(SBEnrc Stakeholder Workshops 2011). Collecting local data is also
significant as aspects such as climate, demographics, infrastructure and
government play a pertinent role in biophilic urbanism. Local exploration
to capture the successes is important for cities to gain confidence to pursue
a project further and to mainstream it wider. As biophilic urbanism is still
at its infant stage, data is generally limited and will need to be expanded to
have appropriate figures to present to decision makers to make informed
decisions and to appropriately apply biophilic elements to cities worldwide.
A summary of the emergent priorities in engaging decision makers
have been captured in Table 1-3. It demonstrates the need to further
strengthen these gaps.
Table 1-3. Emergent priorities in engaging decision makers
Emergent
Opportunity in addressing gap
priorities
Government Opportunity to explore incentives such as green door ‘fast
policies tracks’ development application processes; financial incentives
or discounted incentives
‘What’s so’? Opportunity to explore current understanding of biophilia to

present economic, environmental and social benefits.
‘What can be’? Opportunity to present new wealth knowledge to shed light on
what is possible with biophilic urbanism.
Opportunity to present local data to capture the successes to
facilitate understanding and confidence in biophilic urbanism.
Conclusion
Appreciating the emergent gaps in quantifying the full suite of benefits
that arise from biophilic urbanism and that the conventional model of
producing knowledge in relative isolation from other actors in society is
ineffective, this paper highlighted these gaps in economic knowledge and
suggested opportunities for engaging decision makers. The economic gaps
discussed have shown that it is difficult to develop a comprehensive cost-

benefit analysis of biophilic elements. Failure to pinpoint the precise
portion of the increase that is directly attributable to the biophilic element;
failure to identify and quantify social and aesthetic benefits; and failure to
identify the extent of and long-term impact of a biophilic element across
society over time are all impeding the mainstreaming of biophilic
urbanism. The case studies explored have shown, however, that a partial
cost-benefit analysis coupled with government incentives can be sufficient
to justify a biophilic element. In these cases, the economic argument has
been useful in providing a basis for understanding the extent to which
biophilic elements will reduce their existing financial liabilities (for
instance, for stormwater management), and can be used to develop an
appropriately sized incentive. From the public’s perspective, this economic
analysis is a business case to assist in their decision of whether to install a
green roof themselves and will underpin their support of policies and
incentives. Though, it still serves immense value to further explore the
economic gaps highlighted in this paper. Addressing these economic gaps
will further fathom political and community support as presenting the
‘what’s so’ and ‘what can be’ will engage decision makers in biophilic
urbanism.
Hence, the authors summarise some prominent areas of exploration
required for moving forward through targeted research. Further exploration
into the abovementioned gaps creates opportunities to engage decision
makers in up taking, this includes:
Obtaining new knowledge and awareness into direct and indirect
economic benefits of urban nature along with the role of decision makers
in this field;
Sharing knowledge relating to the economic feasibility of retrofitting
the urban environment with nature, highlighting areas of consideration and
the emergent gaps in monetary understanding;
Contributing to a better understanding (improved skills) of two-way
knowledge sharing between environmental economics and decision
makers to highlight and address the gaps within the two fields;
Obtaining new knowledge in relation to economic understanding
of biophilic urbanism and the role decision makers play in broaching the
gap and pushing the business case forward;
Improving skills through a better understanding of the extent to which
the benefits of biophilic urbanism reach and highlighting decision makers'
priorities, this will then be addressed in any business case for biophilic
urbanism.
24 Chapter One
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CHAPTER TWO
CONSIDERING RESEARCH ENQUIRY

INTO BIOPHILIC URBANISM AND OFFICE
WORKER PRODUCTIVITY
ANGELA REEVE, CHERYL DESHA,

AUSTRALIA
CAROLINE KRAMER,
INSTITUTE OF GEOGRAPHY AND GEOECOLOGY, KARLSRUHER
INSTITUTE OF TECHNOLOGY (KIT), GERMANY
CHARLIE HARGROVES
AUSTRALIA
PERTH, AUSTRALIA
AND PETER NEWMAN
PERTH, AUSTRALIA
Abstract
In cities, people spend a significant portion of their time indoors, much
of which is in office buildings. The quality and nature of these spaces have
the potential to be a strong determinant of people’s health and wellbeing.
There is a body of evidence that suggests experiences of nature increase
the rate of attention recovery, reduce stress, depression and anxiety, and
increase cognitive abilities. Further, the presence of nature inside buildings
28 Chapter Two
(such as pot plants and internal green walls) can improve indoor air
quality, potentially reducing illness and increasing cognitive function.
Urban design that integrates nature into the built environment to provide
these benefits, among others, is called ‘biophilic urbanism’ and is the
subject of growing international interest and research. The potential for
these benefits to increase worker productivity in office buildings is of
particular interest, as this could significantly increase the financial
performance of office building-based organisations. However, productivity
is a complex concept that is difficult to define; and affected by a multitude
of factors, which make it difficult to measure. This inability to quantify
productivity increases from investments in nature-experiences in office
buildings is currently a significant barrier to such investments.
Within this context, this paper considers opportunities for research to
explore the relationship between office-based nature experiences and
productivity, by reviewing existing research in this field and reflecting on
the authors’ own experiences. This review has a particular focus on the
importance of quantifying this link in order to encourage private property
owners to voluntarily integrate nature into buildings to provide city-wide
ecosystem service benefits. The paper begins with a contextual overview
of how biophilic urbanism can potentially increase worker productivity.
Existing methods of measuring and evaluating the performance of
biophilic urbanism within the context of office buildings are then
explored, along with a discussion of issues with such methods that are
currently limiting investment in biophilic urbanism to increase worker
productivity and wellbeing. This includes a summary of a survey within a
Perth office building to explore the impact of views of nature through a
window. Drawing on these insights, the paper makes recommendations
regarding opportunities for focusing future investigations to enhance
understanding of how biophilic urbanism can contribute to increased
wellbeing and productivity in office buildings.
This paper builds on work conducted as part of the Sustainable Built
Environment National Research Centre Project 1.5, Harnessing the
Potential of Biophilic Urbanism in Australia, which considered the role of
nature integrated into the built environment in responding to emerging
challenges of climate change, resource shortages and population pressures,
while providing a host of co-benefits to a range of stakeholders.
Introduction
Integrating nature into cities has been a long-held goal of city planners
and decision-makers. Many famous parks in cities around the world are
Enquiry into Biophilic Urbanism and Office Worker Productivity 29
the legacy of an intrinsic understanding that such places provide vital

escape for urban residents from the built environment. As urban
populations have burgeoned, renewed considerations have arisen for how
to maintain this balance between built and ‘green’ environments.
‘Biophilic urbanism’ is an emerging urban design principle that drives the
innovative and intentional integration of nature into the fabric of the built
environment, across a range of scales, to provide a range of benefits to
multiple stakeholders while meeting human’s innate need for contact with
nature (SBE 2012a). As an emerging field of research and practice,
biophilic urbanism is gaining interest globally for how it can balance
density and liveability, while providing environmental and economic
benefits.
Over the last 40 years, much research has sought to describe and
quantify the role that nature plays in urban environments, from an
anthropogenic perspective. Across the disciplines of urban ecology, health
science, psychology, neurobiology, landscape planning, and sociology
(among others), researchers have demonstrated that nature within cities
has the potential to increase the rate of healing from injury (Ulrich 1984);
improve general health and well-being (Tzoulas et al. 2007); reduce stress
(Hartig et al. 2003; Kaplan and Kaplan 1989; Ulrich 1991); increase
cognitive abilities and attention recovery (Beatley 2009; Jaffe 2010;
Kaplan 1995; Staats, Kieviet and Hartig 2003); assist childhood development
(Beatley 2011; Louv 2005; Taylor, Kuo and Sullivan 2002) and reduce
crime and violence and increase public amenity (de Vries et al. 2003; Joye
2007; Sullivan, Kuo and Depooter 2004). This research has underpinned
efforts by many urban municipalities to incorporate the use of urban nature
into urban planning strategies (for example, City of Chicago 2008; City of
Melbourne 2012; NYC 2010).
In dense, inner-city areas, competition for land use is high, and most
land privately owned. This competition presents unique challenges to
biophilic urbanism, as governments generally cannot mandate biophilic
retrofits to existing buildings, unless these are otherwise being
redeveloped or renovated (and therefore require building approvals).
However, most inner city buildings have long life spans, and may not be
renovated or redeveloped within near timeframes. Thus, achieving
biophilic urbanism in dense inner city areas will likely require the
voluntary action by private property owners.
Experience in Australia suggests that, in additional to more local
experience with biophilic elements, property owners require a cost-benefit
analysis to justify biophilic retrofits, and assistance from government in
designing and financing elements (SBEnrc 2011). However, quantifying
30 Chapter Two
many of the benefits of nature in office buildings is notoriously complex.

This is especially the case for what is potentially the greatest financial
benefit: improved productivity of workers (Heerwagon 2000). The
research summarised above highlights many ways in which experiences of
nature influence humans physically, neurologically and behaviourally, and
it could be hypothesised from these findings that nature may also enhance
worker productivity. As labour costs can account for 70-80 per cent of an
office-based company’s costs (Haynes 2007), improved productivity can
represent a significant financial benefit. However performance metrics are
needed to quantify the link between nature-based experiences, worker
productivity, and business performance as an aggregate of individual
worker performance. Whilst there has been much research that has
considered a range of human responses to certain nature-experiences, there
has been far less that has attempted to consider ‘productivity’ and a
significant gap is observed in reviewing the body of work in this field to
provide insights and guidance to researchers in this field in terms of:
- The information needs of decision makers in office-buildings to
unlock investment in integrated nature;
- The extent to which existing research is meeting these
information needs, and persisting gaps in this knowledge; and
- The sufficiency of existing research designs and methods in
generating knowledge to meet these information needs.
Within this context of research into biophilic urbanism, this paper
reviews existing literature concerning the impacts of office-based
experiences of nature on office workers to consider the knowledge gaps
highlighted above. A study conducted by the authors to investigate
impacts of views of nature in an office building in Perth, Australia, is also
considered to add additional insight to this discussion. The paper aims to
provide a frame of reference for future researchers, exploring opportunities
to build on the field of enquiry to date. This includes a discussion of the
range of existing research methods in the field, and findings to-date on this
emerging area of inquiry related to well-being and productivity in office
buildings.
Overview of existing research into productivity benefits

of biophilic urbanism
In this section we overview existing research into how experiences of
nature affect office workers’ productivity. This includes a review of
research approaches used in studies evaluating workplace, research

methods to collect data on how nature experiences affect productivity, and
a consideration of the advantages and challenges for each. Some of the
emerging findings from such studies are also discussed, within the context
of how these respond to the information needs of building stakeholders.
Twenty-five research studies were considered in this review. This
included studies that considered the impact of views of nature from a
window, of pot plants or other nature inside the building, being able to
access nature nearby the office, such as on breaks or before and after
work, and living in proximity to green space. A range of research
approaches were considered, including experimental designs, in-situ
studies of real work places, and epidemiological studies that considered
relationships between the health and wellbeing of populations as a whole
and the proximity of individuals to green space. All studies considered are
peer-reviewed from journals, except for one industry report (Heschong
2003).
Methodological considerations
Most studies considered use either an experimental or in-situ approach,
with fewer epidemiological studies of populations—none of which
specifically consider workplaces (see Error! Reference source not
found. for a summary of research designs, and Table 2-2 for research
methods). Across all approaches, there were concerns with some studies
about sample sizes, experimental procedures, and certain methodological
procedures. This review is presented with the intention of highlighting an
emerging discussion about productivity and experiences of nature, and
acknowledges these issues in the field.
Experimental studies were in constructed settings (i.e. not an actual
workplace), in which other variables could be better controlled for, to
allow comparison between control groups. Such studies demonstrate the
effect of various types of experiences of nature on emotional states, such
as viewing nature inside a building, through a window, or walking through
a natural setting; the effect on creative, repetitive, attention-demanding or
skilled tasks; biophysical responses and self-assessed preferences for
nature and evaluation of performance and workplace satisfaction. Such
approaches and methods target specific skills, tasks and responses in
controlled settings, which can make the studies less representative of
actual workplaces that are more complex, involve longer timeframes, and
a wider variety of skills and tasks.
Research design Common measures of productivity Advantages Selected methodological Examples
used challenges
32
In-situ studies: Self reported performance and Investigate real Highly difficult to control Fjeld et al, 1998;
Studies undertaken in satisfaction measures, including workplaces for other variables, and to Leather, et al, 1998;
real workplaces, stress, productivity, job satisfaction, where real establish a means of Kaplan, 1993;
where comparisons intention to quit, and physical workloads and evaluating ‘productivity’ Kaplan et al, 1988;
can be made between wellbeing. tasks apply, thus with real-world work Bringslimark,
workers with giving a more tasks, due to these Hartig and Patil,
different access to Job statistics, for example, billable realistic context generally being non- 2011
nature; or of the same hours, or number of sick days to the research. unitized and varying
workers before and taken. between workers and over
after a change in Observed behaviour, such as time.
access to nature. tendency to bring pictures of nature
in the office.
Laboratory/ Quantitative measurement of Variables can Unclear whether results Tennessen and
experimental studies: performance on tests of be more translate to real-world Cimprich, 1995;
Experimental studies concentration, creativity, accuracy effectively working environments. Ulrich, R.S. et al,
undertaken in etc. controlled for, 1991; Hartig et al,
artificial settings, in and Remaining uncertainty of 2003; Chang and
which performance Biophysical measures correlated to standardized the causes for findings, Chen, 2005;
on set tasks is certain emotional states, self- and unitized including the biological or Laumann, Gärling,
evaluated when the reported emotional states and sense tests can be psychological reasons for and Stormark, 2003;
level of access to of wellbeing, productivity, stress or conducted to which experiences of Lohr, Pearson-
nature is varied. other. provide nature appear to affect Mims and Goodwin,
comparable participants. 1996; Larsen, et al,
Self reported perceptions of
Chapter Two
performance, emotional state, sense performance 1998; Stone and

of well-being, satisfaction with results. Irvine, 1994;
environment, etc. Berman et al, 2008;
Shibata and Suzuki,
2002
Epidemiological Studies measure variables such as Large sample Difficulty controling for De Vries et al,
studies: Studies general health and morbidity, and sizes across other variables, or to 2003; Mass et al,
impact of views of nature on workplace productivity.
conducted across correlate this to proximity to green various describe complex 2006; de Vries et al,
large populations space. Studies generally consider demographics, relationships between 2011; Richardson,
mapping physical and where participants live rather than longitudinal variables. et al, 2011; Mitchell
mental wellbeing where they work. None draw a link data available, and Popham, 2007
against proximity to between their findings, and and can No epidemiological
green space. productivity, although such a link consider studies found that
could be hypothesized. variables not specifically consider
possible in other office workers.
studies (such as
morbidity).
Table 2-1. Summary of research designs commonly used to assess the
Productivity evaluation methods Advantages Selected challenges of method Example studies
Standardised performance tests, Performance can be directly Unclear whether such tests recreate Tennessen and Cimprich,
often requiring directed attention, compared between control the experience of working in an 1995; Ulrich, et al. 1991;
creativity, or speed and accuracy. groups, and other variables office, with some suggesting that Hartig et al. 2003;
Performance on such tests can be controlled for. due to the shorter duration and Laumann, Gärling, and
compared across control groups, nature of the tasks, they do not. Stormark 2003; Berman
to determine statistically et al. 2008; Shibata and
significant differences. Suzuki 2002
Standardised tests of emotional Non-intrusive, comparison The relationship between emotional Larsen, et al. 1998;
states, such as evaluating levels possible between control states and productivity is not Berman et al. 2008
of stress or anxiety, generally groups. Tests have completely clear. Questions of
surveys or questionnaires generally been elsewhere transferability of the findings
completed by participants. verified, and are relatively (laboratory), or of controlling other
easy and quick to conduct. influencing variables (real-world).
Self-rating (using surveys, Relatively easy to conduct, Lack of objectivity in measuring Fjeld et al. 1998; Leather,
questionnaires or interviews) of can deal directly with the ‘productivity’ or other factors may et al. 1998; Kaplan 1993;
productivity, stress, notion of ‘productivity’. cause doubt about findings. Kaplan et al. 1988;
concentration, job satisfaction, People’s perception of their Respondents may give false Bringslimark, Hartig and
life satisfaction, satisfaction with experience may be a more responses if they believe an Patil 2011; Bringslimark,
views and/or the office space, relevant than an objective employer could see them, or have Hartig and Patil 2007;
intention to quit, experience of measure, e.g. satisfaction inaccurate assessment of their own Kaplan 2007
symptoms associated with being with light levels, rather than productivity.
in an office building, general an objective assessment of
health and wellbeing. light quality.
Bio-physical measures correlated Ability to measure changes A proxy measure, data does not Chang and Chen 2005;
with emotional states, including that participants themselves necessarily translate to impacts on Laumann, Gärling, and
blood pressure, blood volume may not be consciously productivity. Relatively intrusive Stormark 2003; Lohr,
pulse, electromyography, aware of, providing method, and thus difficult to Pearson-Mims and
electroencephalography, cardiac objective and comparable conduct in a real-life setting. Goodwin 1996
inter-beat interval. data.
Comparison of existing job Use real-life data from Measures are complex and Heschong 2003
impact of views of nature on workplace productivity.
statistics such as billable hours, workplaces and thus influenced by many factors, for
number of pages typed, length of ostensibly reflect actual instance people may take sick leave
phone calls in call-centres, and performance indicators. when not sick, and billable hours
number of sick days taken. may reflect changes in workload, or
employees’ motivation.
Observation of behavioural Investigates actual Shows preferences for certain Heerwagen and Orians,
Enquiry into Biophilic Urbanism and Office Worker Productivity
patterns, such as bringing plants behaviour in the workplace, scenery but not necessarily how this 1986; Biner et al. 1993;
into an office when window and is non-intrusive. influences productivity. Behaviour Bringslimark et al. 2011
views of nature are not available, may reflect other variables such as
preference for desks with social norms, or company policies
window views of nature, or and practices.
Table 2-2. Research methods commonly used to gather data on the
33
state; compare existing data such as sick leave or billable hours, or

In-situ studies are conducted in real workplaces, often considering
workers who have different amounts of exposure to nature experiences
(such as different window views), or considering workers before and after
applicable to real workplaces, however it is difficult to control for the

observation of behaviour. The findings from these studies are inherently
an office renovation or move. These studies commonly use methods
including self-assessment of performance, satisfaction, health and emotional
many other important variables that affect worker productivity, may not be
seeking natural spaces for breaks.
34 Chapter Two
generalizable across all workplaces, and consider factors thought to influence

‘productivity’ rather than productivity itself. Additional methodological
concerns include that random sampling is virtually impossible, there are
risks of self-selection bias, and respondents may not give truthful
responses if they fear employers could access data.
Epidemiological studies consider population data and look for
correlations between people’s proximity to green space, and measures of
health, mortality and lifestyle. These studies can identify patterns and
relationships, although provide little indication of the impact of office-
based nature experiences independent from the experiences people have
outside of the office. Methodological concerns include whether findings
result from selection, whereby healthier people move to places with more
green space, and the influence of other health-influencing variables on
findings.
Emerging consensus of the impact of nature experiences

on workers
An overview of emerging consensus from the studies reviewed is
discussed in the following sections, along with some identified gaps in the
existing knowledge. These gaps are highlighted to enable a discussion
about the inherent complexity of quantifying the effects of nature on
workers in this manner, and potential opportunities for future research.
Performance on tasks and tests

Experiences of nature have been found to restore people’s ability to
direct their attention and to sustain activity while inhibiting competing or
distracting stimuli (Berman, Jonides and Kaplan 2008; Hartig et al. 2003;
Laumann, Gärling and Stormark 2003; Lohr, Pearson-Mims and Goodwin
1996; Tennessen and Cimprich 1995). However, there are inconsistencies
in results. One study reviewed found that performance decreased on
attention-demanding tasks with more plants present in a room, potentially
due to the plants themselves being distracting, although performance
improved on creative tasks (Larsen et al. 1998). Another found that men
performed better on creative tasks when plants were in the room, but not
for repetitive sorting tasks, and women were unaffected (Shibata and
Suzuki 2002). Some studies found workers completed repetitive tasks
faster when they had a view of nature (Heschong 2003; Lohr, Pearson-
Mims and Goodwin 1996).
Gaps in the knowledge: The reasons why the observed effects on

performance occur are not understood, potentially underpinning the
inconsistencies found. Consequently, it is still not known what facets of
nature experiences affect performance, and thus how these could be
optimised. Further, while effects have been observed, there is as yet no
consensus for how to quantify the relationship, and thus no apparent
mechanism for predicting the improved performance of workers from a
given biophilic retrofit.
Emotional state
Research has shown that experience of nature appears to foster more
positive emotions (Larson 1998; Hartig et al. 2003) although one study
found no effect (Shibata and Suzuki 2002). Studies show a faster and more
complete recovery from stress when watching natural settings (Ulrich
1991), lower job stress (Leather et al. 1998) and less nervous and anxious
with more plants and views of nature (Chang and Chen 2005).
Gaps in the knowledge: The degree to which this improved mental
state correlates with improved worker productivity or reduced labour
costs to businesses, or the amount of nature experience needed to produce
a given change in emotional state, is not clear. Again, the reasons why the
observed effects occur are not understood, although hypotheses exist.
There are some inconsistencies in results, which suggest that the
relationship between nature experience and emotion may be complex.
Perceptions of, and satisfaction with, work

Views of nature through a window are correlated with a reduced
intention to quit and an increased sense of general wellbeing (Leather et al.
1998), lower self-reported frustration, more patience, greater sense of
challenge, greater enthusiasm for work, and higher life satisfaction and
overall health (Kaplan 1993), and evoke higher aesthetic responses in
people and more positive feelings of wellbeing, than do urban or non-
natural environments (Ulrich 1979; Ulrich 1983). Indoor plants appear to
increase the perceived comfort and attractiveness of office environments
(Larson et al. 1998).
Gaps in the knowledge: Why the observed effects occur, and how this
compares to other potential improvements to the workspace. The studies
did not evaluate how perceptions of, and satisfaction with work, correlated
with the actual length of employment, or any objective measure of work
36 Chapter Two
commitment. The degree and quality of nature experience necessary to

provide the observed is not known.
General health and wellbeing

Desk workers with views of nature report fewer ailments (Kaplan,
Talbot and Kaplan 1988, cited in Kaplan 1993). Having pot plants in
offices is also found to significantly reduce the total number of self-
reported symptoms commonly found in office workers (Fjeld et al. 1998),
and the same effect was found in a hospital and high school (Fjeld 2000).
Employees were found to take less sick-leave when they had greater views
of nature and more natural sunlight at their desk (Elzeyadi 2011). On a
broader scale, living in proximity to green space is correlated with
improved health (de Vries et al. 2003).
Gaps in the knowledge: What critical thresholds of experiences are
needed to produce such benefits, and whether a marginal benefit is
received by people who experience much nature outside the workplace.
How these benefits compare to those obtained from other measures to
improve health and wellbeing, and thus how to prioritise investments.
Finally, there are many aspects of nature experiences that could intuitively
be said to improve health and wellbeing, including improved air quality
and micro-climate (indoor plants), motivation to walk, cycle and exercise
(nearby green space), reduced stress and increased positive emotion (views
of nature), among potentially others, and the reasons for observed benefits
are not always known.
Preference for nature and natural settings

Workers without windows are more likely to bring plants and pictures
of nature into their workspaces than workers with windows, independent
of age, gender, type of office, job demands, control over work, and
personalization (Bringslimark, Hartig and Patil 2007). Employees are also
found to seek places with trees and flowers for places outside to sit and
have a break, show preferences for natural landscaping around buildings
(Kaplan 2007). Others have shown that when people are in need of mental
recovery, they are more likely to seek, and show a preference for, natural
views and places than at other times, potentially displaying an inherent
understanding the benefits of such experiences (van den Berg, Hartig and
Staats 2007).
Gaps in the knowledge: Other factors may motivate people’s
preferences for natural settings, such as social convention, the ‘neutrality’
of a nature themed picture in the office space as opposed to other more

personal images and/or objects. Such studies identify people’s preferences,
but not how these impact on their work performance, or the organisation’s
financial outcomes.
Investigating the impacts of nature in an Australian office

building
The authors conducted a survey study in an Australian office building,
in the City of Perth, to investigate whether the findings from
predominantly international research would also be demonstrated in
Australia. Limited research had been found investigating the impact of
nature on office building workers in Australia, and the authors hypothesised
that differences may exist due to climatic and cultural factors, as well as
differences between the predominant forms of the built environment in
Australia compared to cities elsewhere.
One side of the study building overlooks extensive parkland,
incorporating large trees, shrubs and grassland, whilst the other side
overlooks a car park and buildings. Project partners for the research team
occupied levels 4 and 5 of the building, and assisted the research team in
developing and distributing the survey via email to all employees on those
levels, and allowed the survey to be completed during working hours.
The study was thus in-situ, and used self-rating measures via an online
survey to evaluate participant perceptions of their workplace stress,
productivity, symptoms associated with spending time in buildings, and
preference for nature when taking a break from work. This data was
correlated with the view participants had out the window, as well as views
of pot plants or depictions of nature inside the building. A total of 171
employees completed the survey, which was run twice (109 in December
2011, 62 in February 2012, no statistically significant differences were
found between responses given in the two survey rounds).
No statistically significant differences were found between any of the
responses for workers with a view of nature, as opposed to a view of the
built environment or no view out a window, nor to being able to see
depictions of nature or pot plants (SBEnrc 2012b). A range of potential
reasons for why the findings of this survey differed to those encountered in
the literature were proposed, and are discussed in brief in the Discussion
section of this paper.
38 Chapter Two
Discussion – measuring and quantifying productivity

improvements
In this section, we consider the emerging body of knowledge about the
possible links between experiences of nature and worker wellbeing and
productivity within the context of informing and enabling decision makers
to enhance their property’s biophilic attributes. We also consider some
potential implications of gaps in the knowledge and limitations of existing
approaches to the mainstream adoption of biophilic urbanism.
The emerging research approaches used in the reviewed studies give
multiple perspectives on the link between productivity and experiences of
nature. It is well acknowledged in the literature that worker productivity is
affected by many factors, and controlling for these factors is a key
challenge in research. Research to date has largely been either in artificial
settings, with uncertainty about the degree to which results translate to
real-life work settings; or in real-life settings, in which the extent that
other variables influence findings is unclear. The authors similarly
experienced the difficulty of assessing impacts on productivity in isolation
of other variables in a real-world setting (for example, in the study of an
Australian office building). Large epidemiological studies typically
correlate health, well-being and satisfaction of large populations with
proximity to green space. However, these consider where people live
rather than work, and do not consider productivity directly. In all studies,
it is difficult to isolate the effect of experiences of nature from that of other
variables. A range of methodological challenges in general raises
questions about the transferability of these findings.
These challenges are to a large extent underpinned by the difficulty in
defining and measuring ‘productivity’ in a knowledge-based office setting.
Whilst there are some relatively unitised tasks that can be measured and
compared, such as typing or filing, the kind of workplace activities that
likely hold the greatest potential for financial benefit in organisations are
typically non-repetitive, non-linear, often involve creative thought, have
outcomes that are often not immediately evident, and involve multiple
employees. Consequently, almost all current research methods evaluate
factors considered to influence productivity rather than ‘productivity’
itself, or they assess performance on a standardised test intended to
replicate some isolated aspect of workplace tasks.
These challenges in directly and objectively measuring productivity
lead to a mosaic of perspectives about ways in which people respond to
experiences of nature, with none that directly and quantifiably describe the
relationship. As a consequence, globally within the field there is still
limited ability to predict productivity increases and financial outcomes

from enhancing worker experiences of nature. Considering the experiences
of the authors, and those of researchers discussed in this review, it seems
unlikely that the relationship could be described in ways that would
answer the questions that could influence mainstream investment
decisions. Such questions include:
- What percentage increase in productivity could be expected from
increasing the biophilic urbanism of an office building;
- What amount of office-based nature is needed to create
benefits—e.g. how many pot plants and in what proximity to
workers, what size windows with what quality of view, or what
quantity and quality of nature in proximity to the office building
to provide nature-based sites for breaks;
- Which kind of nature based experience is likely to provide the
greatest benefits; or
- How do the benefits of office-building nature compare to other
factors influencing worker productivity.
Future researchers and advocates in this field may need to reconsider
the approach to investigating and enabling office building biophilic
urbanism. The discourse may need to be reframed, recognizing the
limitations of current approaches, as well as the changed nature of
knowledge based economies and complexities of measuring productivity.
In knowledge-based economies, financial outcomes are increasingly
determined by non-linear, collaborative and creative processes (Powell
and Snellman 2004) and the ability to attract and retain talent (Florida
2007). Within this context, research that meets the information needs of
employers and employees about the potential impact of nature experiences
on overall experiences and performance at work, without necessarily
quantifying productivity, may influence market dynamics and decision-
making. Comparisons can be made with the broader field of ‘green
building’. A study of the global green building market found that between
2008 and 2012 there was a significant shift in the desire to, and
motivations for, building green. Green building is increasingly seen as a
business opportunity, with client demand and market demand the
dominant forces influencing green building decisions. Improved health
and productivity are important factors influencing these decisions, despite
a limited number of firms actually tracking the performance of buildings
(McGraw Hill Consulting 2013). A growing number of showcase biophilic
buildings suggests that there are currently motivations that encourage
40 Chapter Two
building owners and occupiers to invest in biophilic retrofits, which could

be transferred to the mainstream market.
With these considerations in mind, some possible future research
directions that emerge include:
- To investigate what other factors are currently motivating
decision makers in ‘pioneering’ biophilic buildings, and how
these can be made more prominent in the mainstream market;
- To consider shifting the research focus towards creativity,
collaboration, and worker attraction and retention;
- Considering biophilic urbanism as a ‘precondition’ for these
factors, within a complex system of factors that influence people
in office environments, and company financial performance;
- To thus consider more holistic, case-study investigations that
synthesise the lessons of pioneering biophilic buildings within the
rich context of knowledge-based workplace dynamics, to avoid
both reductionist approaches and ‘silver-bullet’ conversations,
and enable a more robust consideration of the role of integrated
nature in the kinds of workplaces, and labour markets, seen
today.
Conclusions
Productivity is a complex and difficult to define concept, and
influenced by many factors. Whilst unlikely to be a ‘silver bullet’, the
emerging consensus of research studies suggests that biophilic urbanism
has the potential to provide a range of benefits to office-building workers
that provide a precondition for productivity and could increase the
financial performance of their organisation. However, current limitations
in research approaches and methods are such that for a decision-maker in
an office-based organisation, there are still uncertainties about the pay-
back period of improving access to experiences of nature, how such
measures compare to other interventions to improve productivity, and
what kind and amount of nature experiences to prioritise. Reductionist
approaches seeking to isolate and quantify the impact of nature
experiences on workers may be ultimately unsuccessful in the complex
environment and nature of knowledge-based work. Despite these
challenges, there are a growing number of buildings that integrate nature
into, onto and around them. These pioneering efforts demonstrate that, for
a variety of reasons that are beyond the scope of this paper to explore,
certain organisations are able and willing to make investment decisions

based on information available at that time.
With all of the challenges presented in this paper, there is a clear
opportunity for furthering inquiry into holistic case studies of pioneering
biophilic buildings, to better understand the motivations that have driven
these investments and to consider the benefits they provide. Future
research can be framed by an understanding of what attracts skilled
workers, what motivates decision-makers in pioneering biophilic
buildings, and how value is created in today’s workplace. With this
knowledge, researchers may play a role in providing catalytic information
to employees, employers, property owners and both the labour and
property market in general about the role of nature experiences in
enhancing what is of importance to each of these groups of people.
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oils or with the ichthyol-mercurial ointment. It has been successfully
treated, as is keloid, by the subcutaneous use of a 10 per cent.
alcoholic solution of thiosinamin. The ultraviolet rays and even the x-
rays, used judiciously and carefully, may also be of service.
Rhinophyma.—This form of tumor is to be differentiated from
rhinoscleroma, the latter being due to a peculiar specific bacillus,
while rhinophyma is a filth disease, due to hypertrophy of the
sebaceous structures of the nose from obstruction of the sebaceous
ducts. It is often seen among alcoholics, perhaps less frequently at
home than abroad. Pathologically it consists of enormous and
irregular hypertrophy of the sebaceous gland elements and
connective tissue of the skin of the nose. Each hypertrophied gland
secretes in proportion to its increase in size, and even the vessels of
the part become engorged. In consequence there results a
lobulated, distorted, most disagreeable appearance, which often
becomes exceedingly offensive. The tumors thus formed sometimes
increase to a size sufficient to interfere with breathing and with
feeding. The resulting nasal enlargement is usually trilobed. The first
impetus to the overgrowth comes sometimes from such cutaneous
irritation as frostbite, or local irritation of some kind.
Treatment.—The treatment of rhinophyma consists in the
unrestricted use of scissors and the sharp spoon, with the
preservation of so much of the integumentary structure as may
serve to cover the reduced dimension of the nose. These lesions will
bleed freely at first, but bleeding is usually easily checked. When a
plastic covering of the defect is impossible, the surface may be left
to granulate, with a certain feeling of security that the cicatricial
contraction following will reduce the enlargement to normal
proportions.
Xanthoma.—This name is applied to a macular lesion, papillary
or tuberculous, marked by the appearance of yellowish spots,
occurring singly or in groups, often about the eyelids, but seen
anywhere upon the skin. When occurring in papules it is called
xanthoma planum; when in nodules, xanthoma tuberosum. There is
a variety met with in diabetes which is temporary and usually
disappears spontaneously.
Treatment.—The treatment for xanthomatous patches is either
electrolysis or complete excision, under local anesthesia.
Keratosis.—Keratosis is a term applied to thickening of the
normal epidermis, occurring in limited areas, the skin being
transformed into tense or almost horny tissue. The form which
occurs in elderly individuals is called keratosis senilis. It occurs upon
the face, the hands, and forearms, but may be seen on any part of
the body. The involved areas become discolored, sometimes by true
pigmentation, more often by a deposit of dirt. As long as epithelial
reproduction occurs away from the basement membrane the lesions
are simple and innocent, but in elderly people it requires but little
irritation to provoke a down-growth of epithelium, and then the
development of epithelioma is rapid.
Treatment.—These reduplicated epithelial elements can be kept
soft by an application of equal parts of glycerin and liquor potassæ.
After being softened they may be easily scraped down to a normal
level, but will later reform. If they begin to ulcerate they should be
excised. Should excision be declined the area may be treated with
the thermocautery or with one of the caustic pastes.
Vascular Growths.—These have already been mentioned in the
chapter on Tumors, under the head of Angioma. So far as the skin is
concerned they usually occur in the shape of nevi (called strawberry
growths) or the more disseminated form, sometimes involving
considerable areas, commonly known as “port-wine marks,” which
are essentially cutaneous telangiectases, are almost always of
congenital origin, and frequently appear in complete form even at
birth. They may occur rapidly or slowly. An isolated nevus should be
treated by complete excision. Large vascular areas, or port-wine
marks, are best treated by repeated electrolysis. If treated early they
are sometimes eradicated by the local use of sodium ethylate.
The so-called nevus pigmentosus, or pigmented mole, is generally
of congenital origin, and may or may not be accompanied by
vascular changes. It is not infrequently covered with hair, and
sometimes forms a patch of considerable size, often upon the face.
These lesions occasionally occur in such form as to entitle them to
be styled nevus verrucosus or nevus pilosus. Occurring upon the
back or trunk they are usually disregarded. When upon the face they
should receive surgical treatment.
Treatment.—Excision is, of course, the best method of treatment
unless a disfiguring scar be feared. This can usually be prevented by
proper plastic methods. When excision seems inadvisable electrolysis
is the next best method of attack. No matter how vascular may be
the lesion itself, the vessels a short distance from the margin of
these growths are rarely dilated, and hemorrhage is not a feature
which need deter one from radical treatment.
Lymphangioma.—This has also been described in the chapter on
Tumors. A circumscribed form is occasionally found in or beneath the
skin. It occurs early in life, constitutes a more or less sessile tumor,
which collapses on pressure, fills slowly, its surface being often
irregular, warty, or horny. Should the surface be injured lymph will
escape rather than blood. An extended form of it constitutes one
kind of elephantiasis. (See chapter on Lymphatics.) Any septic
infection of a growth of this character is likely to result seriously and
at once.
Treatment.—The best treatment is excision under thorough aseptic
precautions; next to this is destruction with the cautery, which will
lead to resulting sloughing and cicatrization.
Malignant Disease.—All forms of cancer may appear, primarily,
in or upon the skin. From the ordinary surface epithelium springs
epithelioma; from the glandular elements possibly round-cell
carcinoma; and from the mesodermic elements any of the radical
varieties of sarcoma, while endothelioma is less common.
Epithelioma.—This is a frequent infection of the skin, which may
arise primarily as an original lesion, usually following surface
irritation, or secondarily, either as the extension of similar disease
from other parts or of degeneration of previously innocent epithelial
tumors. Epithelial outgrowth, so long as it be an outgrowth, and do
not transgress the limits of the basement membrane, is essentially
innocent in character; but so soon as growth in the downward
direction begins we have the beginning of a skin cancer, which may
proceed to fatal extent if not promptly recognized and properly
treated. These growths vary very much in rapidity and malignancy.
Occurring upon surfaces which are kept constantly moist and warm
they develop more rapidly, as upon the tongue, within the vulva,
rectum, etc. The slowest form of growth of this kind is the so-called
rodent ulcer. Epithelioma which begins in or upon the skin or mucous
membrane tends to spread to and involve everything in its
neighborhood; even bone and cartilage succumb to its ravages, and,
becoming involved, lose all their characteristics and melt away in the
surrounding ulcer. This produces in the course of time hideous and
serious developments. No tissue is exempt from its ravages, and yet
life may be prolonged for many years, even when the face is almost
entirely eaten away. Epithelioma and rodent ulcer have been
described in the chapter on Tumors.
More deeply seated Fig. 108
carcinomas of the
skin infiltrate in both
directions alike, and
grow downward,
sometimes in cylinder
form, thus giving rise
to a clinical type
called cylindroma.
Lenticular carcinoma
is also described as
differing from the
ordinary epithelioma,
in that it exhibits a
true alveolar
structure. This form is
rare, and is Epithelioma.
distinguished from
the common form by the absence of the so-called “pearly bodies,”
which characterize common epithelioma. The lenticular form is most
often seen in recurring cancer of the breast, or in the vicinity of
scars showing where deep-seated cancer had existed.
Diagnosis.—Epithelioma in its various forms should be
distinguished from skin lesions due to syphilis and tuberculosis. A
diagnostic table has been given (see p. 293) by which diagnosis as
between it and lupus may ordinarily be made. The lesions of syphilis
are usually multiple and accompanied by other manifestations which
stamp their character. There is, moreover, usually a history which will
be suggestive if not actually helpful. In cases of actual doubt, as
upon the tongue and elsewhere, the therapeutic test may be
applied. If resorted to, it should be vigorously made. When mercurial
inunction is thoroughly practised, and the internal administration of
the iodides effects no improvement within three weeks, the
hypothesis of syphilis may be abandoned.
All cancerous lesions tend to advance and to destroy in spite of all
local measures. There never appears about them any indication of a
tendency toward cicatrization, and, while the edges of malignant
ulcers may be thickened and everted, the more central portions are
always excavated. They cause, moreover, involvement of the
adjoining lymphatics, although this may be said as well of syphilitic
and tuberculous lesions.
Treatment.—Concerning the treatment of epithelioma and other
malignant skin diseases there is little to be said which has not
already been summarized in the general considerations concerning
the treatment of cancer. Radical excision of the original lesion, in its
early stages, will usually lead to final recovery. If there be
involvement of the lymphatics the indication is made thereby more
positive for cleaning out all infected areas, while, at the same time,
the prognosis is rendered less favorable. There comes a time in the
history of all these cases when excision can be recommended only
as a palliative measure, i. e., when it may be regarded as useless. In
the more hopeless cases benefit will but rarely be obtained from the
use of x-rays, ultraviolet light, or radium.
Paget’s Disease.—Paget’s disease includes lesions now regarded
as a precancerous stage, which appear upon the breasts and around
the nipples of women during the middle decades of life. Something
similar is seen in other parts of the body and in both sexes, but it is
most common around the nipple on one side. For a long time it
appears as an ordinary eczema, which, however, does not tend to
heal but to spread, while the skin beneath becomes more or less
infiltrated. A gradual retrocession of the nipple is usually seen.
Certain discomfort accompanies the lesion, which may go on
indefinitely until it becomes unmistakably cancerous. This is a
precursor not so much of round-cell cancer (scirrhus) as of
epithelioma. Eczema of the nipple is to be regarded with suspicion,
especially when occurring after the menopause. Until diagnosis is
fairly established it is best treated with soothing applications. So
soon as the cancerous stage has been determined the breast should
be removed. (See Plate XXVI.)
Other forms of malignant or border-land tumors which occur upon
the skin are chimney-sweeper’s cancer, paraffin cancer, and that
met with in aniline workers. Chimney-sweeper’s cancer was the
name applied to epithelioma of the scrotum occurring among a class
of laborers whose occupation is now almost entirely extinct. It began
usually as papilloma and merged into epithelioma. Among workers in
paraffin and coal-tar factories there is an analogous lesion, the result
of surface irritation, the skin becoming dry, thickened, covered with
acne-like pustules, and then with papillomas which ulcerate and
frequently change over into true epitheliomas.
Sarcoma.—Only the outer layers of the skin are truly epiblastic.
In the depths of the integument mesoblastic elements enter largely,
and from these various forms of sarcoma may develop. These have
already been treated in the chapter on Tumors. They may be single
or multiple, and a general disseminated sarcomatosis is occasionally
observed. It corresponds to miliary tuberculosis, but presents many
distinctive lesions in the skin, by which it may be easily recognized.
A form of multiple pigmented sarcoma involving the hands is
represented in Fig. 109. These growths are almost always tender on
pressure and more or less painful. They coalesce and finally form
fatal lesions.
Melanoma.—This term was introduced by Virchow, who made it
cover all pigmented growths. By common consent it is today limited
to tumors of the skin and uveal tract which contain pigment;
metastases may occur in any or all of them. They occur as malignant
degenerations of nevi, moles, and other small growths. Pathologists
are still disputing as to whether they should be considered sarcomas
or endotheliomas. The coloring matter which they contain is
amorphous, finely granular material, lying between the cells in
moles, but occurring free in the tissues and blood and even in the
urine. It is soluble in strong alkalies, from which it can be recovered
as melanic acid, containing a small proportion of sulphur. Of its
origin nothing is positively known. It seems to be generally accepted
that the deposit of pigment is not of itself a causative agent of the
growth of the tumor, but that the growth of cells and their
pigmentation are coincident processes. Johnston has offered much
evidence lately to the effect that growths from nevi are really of
endothelial origin. Hutchinson has described melanotic whitlow. (See
below, the Nails.)
Melanoma is a pigmented ulcerating neoplasm, which possesses at
first only a local malignancy like that of rodent ulcer; the more it
assumes the endotheliomatous type of growth the more it tends to
disseminate and to prove fatal.
The melanoma arising from a mole or nevus, thus known as
melano-endothelioma, begins to increase in size and becomes more
full, as well as to assume a darker tint. For a variable time it is a
single, rather firm, gradually growing, flat tumor, rarely ulcerating,
but sometimes exuding a thin dark fluid. Suddenly there appears
rapid local spread as well as dissemination. The latter may be first
noted in the adjoining lymph nodes. Thus numerous secondary
tumors may be felt in and beneath the skin, at first colorless,
becoming more or less rapidly pigmented. Metastasis may take place
to every organ in the body, but usually the liver and lungs—less
often the brain—are involved. In one case known to the writer the
heart was a mass of nodules of this same secondary character.
Another expression of the same serious condition is seen in a
lesion called by the French malignant lentigo, which also begins with
pigmented spots, on the feet of old men, sometimes upon the face.
These lesions cause thickening of the skin and early ulceration.
Rodent ulcer, which is one form of epithelioma, occasionally
assumes the melanotic type, and is called melano-epithelioma.
Fig. 109
Fibrosarcoma of hands. (Hardaway.)
The most marked collection of pigment in the human body, within

small space, is along the uveal tract within the eye, and orbital
melanomas are not infrequent. Beginning within the sclerotic they
rapidly perforate this dense membrane and spread to adjoining
tissues, while dissemination and metastasis occur early and rapidly.
Treatment.—For melanoma there is but one successful treatment,
and this is successful only when practised early, i. e., complete
excision or destruction. Every mole, nevus, or other skin lesion which
shows the slightest tendency to changes noted above should be
promptly excised, along with a wide area of its surrounding tissue. It
may be thus possible to make a radical cure. Neither x-rays nor any
other less radical method of treatment will have the slightest effect.
The treatment of any case left to itself until mistake in diagnosis is
impossible will probably be of little avail.
SKIN APPENDAGES; HAIR AND NAILS.

The only lesions of the hair and hair follicles that concern the
surgeon are those which have been described under the head of
Syphilis of the Skin, or some of the congenital growths, such as
plexiform neuroma, lymphangioma, etc., whose surfaces are
frequently pigmented and hairy, and may call for excision, along with
the underlying tumor.
The Nails.—Onychia implies any disturbance of the nail border
and matrix. Simple onychia occurs frequently in the fingers of
marasmic children. It is evidenced by softening and swelling of the
skin around the nail, by more or less pain, disturbance of circulation
beneath the nail, which becomes finally loosened, sometimes leaving
a foul ulcer. This ulceration may extend and involve nearly the whole
finger. It may occur in one or in several fingers. Lesions of this kind
are regarded as local infections, occurring usually in vitiated
constitutions. It is a common expression or complication of syphilis;
when of such origin it yields readily to treatment; at other times it is
often slow and tedious. Except in specific cases, where mercurials
locally and internally will usually be sufficient, the treatment should
be radical and should consist of thorough exposure of the ulcerating
and fungous surfaces, thorough curetting, and the use of suitable
caustics and antiseptic dressings.
Onychia Maligna.—Onychia maligna implies, according to some
writers, a more distinctive type of phlegmonous lesion, while the
term has also been applied to malignant ulcers, sometimes
pigmented (see Melanoma above) and sometimes of more ordinary
type. In either type of lesion granulation tissue may be exuberant
and fungating, and it is possible that at times there will be doubt in
diagnosis. The finger-tips, with their peculiar tactile sensibility,
should never be sacrificed unnecessarily, yet any malignant lesion
calls for amputation of the finger.
Ingrowing Toenail.—This is due almost invariably to ill-fitting
footwear, the toes being crowded into too narrow shoes, with too
high heels. The real lesion is not so much an excessive growth of the
nail as overgrowth and overriding of the skin margin around the
matrix. It is painful and annoying, sometimes even disabling. The
maceration of a perspiring foot in a warm and tight shoe serves to
aggravate the difficulty. Palliative treatment is afforded by
chiropodists and quacks, who pack cotton beneath the edge of the
nail and keep patients under treatment for indefinite periods, never
remedying the footwear and never curing the case. In simple cases
it is usually sufficient to excise a portion of reasonably healthy skin
on either side of the terminal phalanx, in order that by cicatricial
contraction the skin may be drawn away from the nail border.
Serious and long-standing cases are best treated by avulsion of the
nail, which may be usually performed under local anesthesia or by
the aid of nitrous oxide gas. The blade of a knife or scissors is driven
under the centre of the nail sufficiently to ensure its passing
completely beneath the hidden matrix. The nail is then split in the
middle, each half seized at its split border by strong forceps, and by
a rapid movement torn loose from its bed. The border of the skin
should be scraped, after which a simple dressing suffices, providing
the operation has been performed with proper antiseptic
precautions.
TATTOO MARKS.
Many an individual is tattooed in youth who would gladly be
relieved of the discoloration later in life. Tattoo marks are difficult to
erase. The following is a method attributed to Ohmann-Dumesnil:
“Wash the skin with soap and water, then with eight or ten fine
cambric needles, tied together and dipped in glycerole of papoid,
tattoo the stained skin, driving the needles into the tissues so as to
deposit the digestive in the corium, where the carbon is located.
Repeat as necessary. The pigment is liberated by the digestant.”
CHAPTER XXVIII.
SURGICAL DISEASES OF THE FASCIÆ;
APONEUROSES; TENDONS AND TENDON SHEATHS;
MUSCLES AND BURSÆ.
Fasciæ and aponeuroses are such non-vascular and indifferent
tissues that they have practically no primary diseases, except such
fibrous and malignant tumors as have their origin in them;
nevertheless they suffer in a variety of morbid processes. They lose
vitality and break down under the influence of both acute and
chronic septic infections. By virtue of their resistant structure, when
they slough they break down slowly and the process ends usually
with the help of scissors and forceps. Many an old suppurating
lesion, especially of the hand and foot, is kept active by the fact that
dense, fibrous tissue remains concealed, which ought to have
separated. Under these circumstances free incisions should be made
and all necrotic tissue trimmed away.
Pus which has formed beneath these fibrous investments will give
pain largely in proportion to the intensity of the process and the
unyielding character of the fasciæ; hence the urgency of early
incision in case of deep phlegmon. Moreover, the direction of least
resistance may cause pus when confined to travel where its
presence is most undesirable, as from the neck beneath the deeper
muscle planes down into the thorax. When pus escapes from
beneath firm tissue it is usually by a small opening, after which it
may spread out again beneath the skin before finally escaping. This
condition has been called “collar-button abscess.” Care should be
exercised in opening the superficial collection not to miss the small
opening. The fascia must be split sufficiently to permit of thorough
cleaning out of whatever collection there may be beneath it.
In the presence of cicatricial contraction of the skin, in shortening
of muscles by chronic spasm, as in wryneck, or in certain deformities
—for instance of the foot—numerous signs of a shortening or
contraction of fasciæ and aponeuroses are seen. In many instances
of club-foot it thus becomes necessary not merely to divide tendons
but to make extensive incisions through the plantar aponeurosis or
elsewhere, in order to release sufficiently the parts whose extension
is desired. Underneath the joint contractures which have been
produced by burns and their resulting scars similar conditions will be
found, which in old and extensive cases constitute bridles of dense
tissue that make it almost impossible to release the parts.
DUPUYTREN’S CONTRACTION.
Dupuytren’s contraction presents the most serious and insidious
appearance of slow but almost irresistible contraction of fibrous
elements which the human body presents. It is produced by
contraction of the palmar fascia, with its numerous minute
prolongations, rather than by flexor tendons. It is seen in the hands
of men who from the nature of their occupations are subject to
much irritation of the palmar surface. It begins nearly always in the
fourth or fifth fingers, but may spread to and involve all the digits
and even the thumb. The view held by Adams and others that it is a
chronic hyperplastic inflammation, with scar-tissue contraction of the
palmar fascia and of the adjoining connective and fatty tissue, which
does not involve them evenly, but only at certain points, is correct,
at least when small nodules may be felt in the palm which are the
precursors of the disease. Either hand may be affected, but
generally both are involved. It is found in from 1 to 2 per cent. of
those who depend upon their hands for their support. Deformity
may proceed to pressure dislocation and finally to ankylosis. Its
causation then is very obscure; it is rarely the result of definite
injury, but follows continued irritation of the surface. It seems to
have a local origin, and yet it is frequently associated with the gouty
diathesis to such an extent that the prolonged use of alkalies will
relieve some cases. The first significant sign of the condition is the
formation of small nodules in the palm of the hand, as stated, and
this usually precedes the finger contraction by a year or two.
Fig. 110 Fig. 111
Dupuytren’s contraction. (Adams.) Dupuytren’s contraction of palmar fascia,

showing contracted fingers. (Burrell.)
Treatment.—There is considerable difficulty in treating these

cases satisfactorily. Cooper advised subcutaneous division of the
tense bands and forcible stretching of the fingers; this rarely proves
sufficient. Adams advocated multiple sections made with a small
tenotome, which is more effective. The best method is that of
Kocher, which consists in excision of the fascial bands by longitudinal
incisions along the cords, and the dissection of the skin from the
underlying fascia. The cord is carefully dissected, with its
prolongations and then completely removed, while the margins of
the skin wounds are closed with sutures. The more thoroughly the
dissection is performed the more satisfactory the result. The fingers
should be straightened and kept from contraction by the use of a
mechanical device. In desperate cases the entire skin of the palm
has been removed, with the diseased fascia, and a plastic operation
made with skin taken from the thigh or the chest, the flap being
sutured in place but not detached completely for ten to twelve days.
Two somewhat allied conditions involving the hand and the foot
are the so-called lock or trigger-finger and hammer-toe.
LOCK OR TRIGGER-FINGER.
Lock or trigger-finger implies a peculiar obstruction to free
movement of the finger, which requires extra effort and then is
overcome quickly, as if a knot had been slipped through a small
opening. It is supposed to be due to a thickening of the tendon at
some point, as by a small fibroma, which becomes entangled along
the course of the sheath, through which it is moved with difficulty. It
is probably due to a local irritation, as in the case of Dupuytren’s
contraction. Injury to the tendon sheath may also produce a similar
condition.
Treatment.—Should it fail to respond to rest and massage the
sheath should be opened and the cause of the difficulty sought out
and removed.
HAMMER-TOE.
Hammer-toe produces deformity with more or less ankylosis. An
angle is formed between the first and second phalanges, and the tip
of the toe is made to bear more than its proportion of weight. This
deformity is in large degree due to the use of shoes which are too
short. In consequence there will develop over the protruding joint a
corn or bunion.
Treatment.
—Should the trouble come on in childhood the toes should be
fastened to a straight splint and shoes for a time abandoned, while
later they should be properly adapted to the needs of the case. In
troublesome cases complete excision of the involved joint gives
satisfactory results.
SURGICAL DISEASES OF THE TENDONS AND

TENDON SHEATHS.
TENDOSYNOVITIS.
Acute inflammation of a tendon sheath is known as tendovaginitis
or tendosynovitis. It always implies an infection, and occurs about
the hands and feet. It is a frequent complication of felons. Many
felons begin in such a manner that it is difficult to decide which part
of the fibrous structures of the finger is first involved. Infection
having once occurred within a tendon sheath will travel rapidly until
it meets with a natural barrier. The frequency of these lesions makes
it important to recall here the anatomy of the tendon sheaths of the
hand. There is a common palmar tendon cavity, which connects with
the thumb and little finger and the space above the annular
ligament, but communication with the first, second, and third fingers
is ordinarily destroyed. This accounts for the apparent vagaries of
cases where infection beginning in the thumb spreads to the little
finger before the others are involved. It will also show the location
where incisions should be made.
Fig. 112
Cicatricial contraction and deformity resulting from consequences of neglected

phlegmon and osteomyelitis of hand. (Lexer.)
Suppurative Tendosynovitis.—Suppurative tendosynovitis

needs prompt intervention, as
adhesions may result from retention of exudate, or lest necrosis of
tendon occur from perversion of its nutritive supply. Ordinarily it is
the result of a local infection, perhaps through a small, trifling
surface irritation, but it results occasionally as a metastatic
expression of gonorrhea, or distinct septic infection. A gonorrheal
tendosynovitis is, however, less likely to suppurate, but more likely to
assume the plastic form and interfere with function by producing
adhesions between a tendon and its sheath. The combination of
virulent bacteria and susceptible tissues will produce local
destruction in almost as short a time as in the appendix. The pain is
intense, because of the inelasticity of the structures.
—Every appearance of this kind calls for early incision, by which not
only the skin but the tendon sheath as well should be freely incised.
An incision at either end of the involved sheath, with flushing and
drainage, may save a tendon and preserve function. Incision should
not be delayed, as destruction may have occurred and deformity be
the result. When the common palmar sheath is involved a long
incision from the base of the index finger, around the base of the
Treatment.thumb
Fig. 113
and up the wrist to a
point considerably
above the annular
ligament, will afford
considerable relief. It
will, moreover,
shorten the time of
ultimate restoration
of function.
—Chronic
tendosynovitis may
be the result of
rheumatism, in which
case it assumes the
plastic form, or of
gonorrhea; the same
being true of a
tuberculous invasion,
which may vary much
in intensity. In the
subacute forms the
deposition of
tubercles may lead to
a plastic outpour
Suppurative tendosynovitis (felon), with sloughing which, being
tendons and necrotic bone. Unfortunately poulticed detached by constant
for two weeks. (Lexer.) motion of the parts, is
Chronic Tendosynovitis. broken into masses
whose minute portions become
rounded off by friction and condensed by time, and appear as the
so-called “melon-seed or rice-grain bodies.” Some of the same
material may be found adherent to the walls of such a cavity. In
slower forms there is less tendency to plastic outpour, but much
more to the formation of granulation tissue, such as is seen in
tuberculous lesions in all parts of the body. When, therefore, a case
of this general character presents we have the signs of local
tuberculosis, or of dropsy of the tendon sheaths, with the fluctuation
somewhat modified by the presence in the fluid of rice-grain or
melon-seed bodies. Should, in such a case, an acute infection be
added we will have the chronic symptoms merged suddenly into
acute. A tendovaginitis of this type appears as a ridge or swelling
along the course of one or more tendons. It will be elastic and
fluctuate in proportion to the distention of the sheath. When the
palmar bursa is involved there is usually, in the palm of the hand, a
bag of fluid which may be forced above the wrist by pressure, while
frequently the little bodies above described are recognizable by the
sensations (crepitus) which they produce. The plastic type rarely
proceeds to suppuration or ulceration unless secondarily infected.
The granulation type proceeds to ulceration and destruction.
Treatment.—Treatment of the rheumatic and gonorrheal forms is at
first rest, with later passive and forced motion, in order to break up
adhesions and prevent their re-formation. If one wait too long he
meets with great difficulty in these efforts and the cases become
exceedingly tedious. Forcible motion should be practised under
nitrous oxide anesthesia and should be repeated every two or three
days. Meanwhile massage should be employed. If pain or reaction
be extreme ice-cold applications should be applied. Extreme swelling
may be combated by the use of a rubber glove. If this be worn,
ichthyol-mercurial ointment should be used beneath it, in order to
promote absorption.
Treatment of the tuberculous cases is often disappointing. Non-
operative measures afford but temporary benefit, while operation to
be effective should be thorough. It should consist of free incision,
with exposure in whole or in part of the affected channel or cavity,
thorough cleaning out of its contents, removal of all edematous or
tuberculous tissue or granulations, and the use of an antiseptic as
strong as it can be employed.
The new opsonic serum treatment, now being placed on trial as
this work goes to press, promises much in the treatment of all these
septic affections, though detailed statements would be premature.
TENDOPLASTY.
It was a step in advance in surgical technique when Stromeyer
and Dieffenbach, in 1842, introduced the method of subcutaneous
division of tendons and aponeuroses, and showed how easily
contracted tendons could be lengthened by tenotomy. From their
time until somewhat recently tenotomy has held its place in the
treatment of various deformities, and until Anger, Gluck, Hoffa, and
others have taught the surgical profession what can be done by
various plastic and suture methods in overcoming defects and
atoning for loss of function in paralyzed muscles. To the surgery of
tendons and muscle terminations have been added the further
resources of tendon suture, i. e., tenorrhaphy, and tendoplasty, by
which latter something more than the mere suture is meant, i. e.,
the plastic rearrangement and grafting of tendons one upon another.
[20]
[20] The method of transplanting one tendon upon another is to be

credited to Nicoladoni, who perfected it in 1882. Later it fell into disuse, but
was revived in this country, especially by Goldthwait, of Boston, in 1896.
Fig. 114 Fig. 115
Fig. 116 Fig. 117 Fig. 118

Fig. 119 Fig. 120 Fig. 121
Illustrating various methods of dealing with tendons in tendoplasty. (After Vulpius.)

Tendon suture is practised as an emergency measure when one or
more tendons has been accidentally divided, this being considered
now as much a part of the surgeon’s duty as to close any other part
of the wound. No additional resource or expedient is needed, it
being necessary only to observe the principles of asepsis, which
should be maintained in every case. A tendon raggedly divided
should be cleanly cut and its edges brought together with formalin-
gut or freshly boiled silk. A series of divided tendons should be
treated after the same fashion, matching the ends as closely and
completely as possible. After uniting the tendon ends, if the case be
clean, the tendon sheath should be closed and the parts put at rest,
in such a position that no tension is made upon the injured sinew
until it is seen to have united.
Fig. 122 Fig. 123
Shortening a tendon.
It was a great service, in which perhaps Gluck figured most
conspicuously, to show that when tendon ends could not be neatly
coapted an animal material could be interposed in such a way as to
serve as a trellis along which cells could group, or around which they
might organize, and thus gradually and finally become a part of the
complete tendinous cord. Silk and catgut have best served this
purpose, and new tendons have gradually formed around these
artificial substitutes, to the length of 10 Cm. In every fresh case
where there has been such loss of original structure as to justify a
measure of this kind, or in certain old cases where tendons have
long since sloughed away, it may be possible to resort to these
expedients.
It has been possible to transplant fresh tendons from the smaller
animals and to see them serve the same purpose in a satisfactory
manner.
Among these methods of tendoplasty is tendon grafting, by which
a part or all of the tendon of an active muscle is inserted into the
terminal portion of a paralyzed muscle and thus made to assume to
a greater or less extent the purpose and function of the latter; in
other words it assists in ingeniously diverting the activity and
direction of a given muscle to a purpose different from its original
intent. By this diversion a more equal or equable distribution of
muscle force is afforded the parts into which the affected muscles
are inserted. For its successful performance only those muscles
which are still active can be utilized. Among the simplest of cases
where this expedient can be used are those produced by traumatic
and peripheral paralyses, or traumatic loss of a given tendon or a set
of tendons. It is rarely to be practised as an emergency measure,
but as an expedient to be availed of later. It finds its greatest
usefulness in cases of long standing. It is equally applicable where
muscles and tendons have been divided by injury, or paralyzed by
injury to their nerve supply, as well as where deformities are
produced by chronic neurotic disturbance, by scars, by excessive
callus, etc. It proves equally serviceable in paralyses of spinal origin,
particularly those due to anterior poliomyelitis.
Tendon grafting will serve both as a substitute in cases of lost
function and as a provision against future deformity. In cases of the
ordinary paralyses of children, tendoplasty should be deferred for
several months after the occurrence of the paralysis. In the case of
growing children it is desirable not to wait too long, as other
objectionable features may present themselves. In the congenital
and hereditary paralyses and in conditions like athetosis or the
dystrophies of syringomyelia, meningocele, etc., also in such
conditions as habitual dislocations of the patella, much can be
accomplished by a carefully planned tendoplasty. It will be easily
seen then how wide a field of usefulness lies before one who
familiarizes himself with the recent technique of tendon surgery.
Fig. 124
Fig. 125
Two methods of tendon implantation and fixation. (After Vulpius.)

Fig. 126 Fig. 127 Fig. 128
Transplantation of a portion of the anterior tibial tendon, into the bone or into the
opposed group of muscles. (After Vulpius.)
So far as technical considerations are concerned these operations

should be performed only with the minutest attention to asepsis.
When this has been secured a permanent dressing may be applied,
the limb being left in the position most desired, and maintained
there for several weeks. For this plaster of Paris makes the best
support. The use of the rubber bandage will permit the operation to
be bloodlessly made, by which it is greatly facilitated. If careful
suturing be practised, there will be but little tendency to subsequent
oozing or interference with repair. Fine discrimination is always
needed in the matter of adjusting the length of tendon ends and the
point of their fixation. A useless tendon which has been long
stretched over a curved joint will have become elongated, and the
tendon to be applied to it should be affixed farther down than would
be otherwise necessary. The disposition of the upper portion of the
useless tendon and muscle may also call for serious attention. It is
rarely necessary to extirpate them. They are already atrophied, and
to remove them would be to still further reduce the dimensions of
the part. The excluded portions can thus be simply discarded. When
there has been deformity with more or less pseudo-ankylosis the
malposition should be forcibly redressed and the tendon grafting
deferred until a subsequent time; the latter, to be successful, should
be performed alone.
Incisions are usually made along and over the course of the
tendons to be exposed, but not so close that the cutaneous scar can
interfere with the tendon sheath. The lower end of a paralyzed
muscle will appear very differently from that of one which is healthy;
in the former instance the tissue will have lost its muscular character,
and will be yellowish white and fatty. A fascia which has been
stretched out of shape may be sutured in folds and will serve of
itself to give support and shape to the part which is renewed.
The methods of uniting tendons are so numerous that they can be
better estimated by a glance at the accompanying diagrams after
Vulpius than by description (Figs. 124 to 128). It is not necessary to
utilize all of the tendon of a healthy muscle, as it can be split and a
portion diverted to its new function. It is not to be expected that
tendons thus arranged will perfectly serve their purpose the first
time they are used. There must elapse a period of education of the
nerves and muscles whose relations are thus altered, and
improvement in the use of the parts thus operated will accrue for
months and even years. It is desirable that tendon surfaces thus
applied to each other be made broad and extensive in order that
their adhesion may be more firm.
A modification of tendon grafting consists in implanting the tendon
end into the periosteum instead of into some other tendon. There
are various ways of making this implantation, either by simple suture
or by boring into the bone or canalizing under a periosteal bridge.
Fig. 129 illustrates how the tendon of the tibialis anticus can be
utilized in both ways. It will thus be seen that a tendon can be given
either tendinous, periosteal, or osteal implantation. Tendons thus
utilized rarely undergo necrosis or degeneration. So long as the
possibility of infection be excluded almost anything can be done with
these structures, in spite of their apparent lack of vascularity and
vitality.
There are times when it is necessary to lengthen a tendon as well
as to shorten it. Fig. 129 illustrates methods by which both of these
measures can be performed. Analogous methods have been
practised with muscles themselves, although here the circumstances
are different and nothing similar can be accomplished. Portions of
Fig. 129
the pectoralis major
have been grafted
into the biceps for
paralysis of the latter.
Liberating the ring
finger in musicians,
by dividing the
accessory tendons of
the extensor
communis digitorum,
is an expedient
suggested some
years ago by Brinton.
It is made by an
incision less than a
quarter of an inch
long, through the skin
Showing methods of lengthening tendons. (Burrell.) and fascia, just below
the carpal articulation
of the metacarpal bone of the ring finger, and above the radial
accessory slip, parallel with and on the radial aspect of the extensor
tendon of that finger. The point of a narrow blunt-pointed bistoury is
then inserted flatwise beneath the accessory slip down to a point
just in front of the knuckles of the ring and middle fingers, where
the blunt point should be felt beneath the skin. The bistoury is now
turned upward, the middle finger strongly flexed, and the ring finger
extended so as to make the slip tense when it is divided. The
accessory slip on the other side of the extensor tendon is similarly
divided through a distinct incision. Snug compression is made with a
bandage over the wounds, with the thumb free, and after two days
the patient is permitted to use the fingers in piano-playing in order
to prevent reunion of cut surfaces.
MYOTOMY AND TENOTOMY.

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Human Environmental Interactions in Cities

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Land Use Planning for Sustainable Development Second

Land Use Planning Made Plain 2nd Edition Hok-Lin Leung

Problems and planning in third world cities Pacione

Land in Conflict Managing and Resolving Land Use

Foundations of Environmental Physics Understanding

Urban Infrastructure Finance and Management 1st Edition

Ethnic Diversity in Eastern Africa Opportunities and

Urban Land Markets Housing Development and Spatial

Nadja Kabisch, Neele Larondelle,

This book first published 2014

Cambridge Scholars Publishing

12 Back Chapman Street, Newcastle upon Tyne, NE6 2XX, UK

British Library Cataloguing in Publication Data

Copyright © 2014 by Nadja Kabisch, Neele Larondelle, Angela Reeve,

ISBN (10): 1-4438-5895-1, ISBN (13): 978-1-4438-5895-3

Foreword ................................................................................................... vii

Part One: Urban Land Use Conflicts and Green Infrastructure

Chapter One ............................................................................................... 12

Chapter Two .............................................................................................. 27

Chapter Three ............................................................................................ 47

Chapter Four .............................................................................................. 66

Part Two: Human-Species Interactions: Challenges on Biodiversity

Chapter Five .............................................................................................. 82

Chapter Six .............................................................................................. 100

Chapter Seven.......................................................................................... 115

Chapter Eight ........................................................................................... 142

Contributors ............................................................................................. 158

Index ........................................................................................................ 163

DAGMAR HAASE, SALMAN QURESHI

Cities are complex adaptive systems embedded within even more

public ecological knowledge and awareness of sustainability challenges.

environment interactions in cities. Within this context, the term “urban

Further, the combination of qualitative or quantitative research combining,

Scope of the Book

conservation and management within the urban ecosystem is highlighted

1. Theory of urban ecology

These topics were intensively discussed at the 1st Congress of the

The Nature of the Papers

Nevertheless, the results can in terms of applied methodological

Structure and Contents of the Book

Part 1: Urban land use conflicts and green infrastructure

determines the city’s green infrastructure properties and identifies the

Part 2: Human-Species Interactions: Challenges on Biodiversity

quick modifications in urban areas could increase selective pressure and

Human Well-Being and Species Richness.” BioScience 62 (1)

McMillan, Tracy E. 2007. “The Relative Influence of Urban Form on a

URBAN LAND USE CONFLICTS

ENGAGING DECISION MAKERS

OMNIYA EL-BAGHDADI, CHERYL DESHA

paper concludes with recommendations for moving forward through

and suggest opportunities of decision makers. The paper concludes with

Table 1-1. Overview of the elements of Biophilic Urbanism.

Ǧ Pot plants in buildings Ǧ Reduces building

Green vegetation up to the size of trees energy efficiency

stormwater management plan and Ǧ Water management

Ǧ Urban parks and gardens placed close to Ǧ Encourages walking