The Clinical Amphitheatre of the riedicoChirurgical Hospital MDCCCXCVU. An Illustrated Description of the Clinical Amphitheatre of the Medico-Chirurgical Hospital Philadelphia Frank Miles Day & Brother Architects C. WILUAM BERGNER, Esq., President of the Board of Trustees. Board of Trustees of the Medico-Chirurgical Hospital. C. WILLIAM BERGNER, President. FRANCIS M. BROOKE, ist Vice President. WILLIAM KING, 2d Vice-President JAMES M. ANDERS, M. D. Secretary. L. WEBSTER FOX, M. D., Treasurer. C. WILLIAM BERGNER, FRANCIS M. BROOKE, WILLIAM KING, Hon. GEORGE HANDY SMITH, W. FRANK HAEHNLEN, M. D., JOHN V. SHOEMAKER, M. D., LL. D., JAMES M. ANDERS,JM. D., LL.D. ERNEST LAPLACE, M. D., LL. D., W. EASTERLY ASHTON, M. D , L. WEBSTER FOX, M. D. D. T. PRATT, Honorary Trustee. WILLIAM S. PRICE, EbQ., Juris Consullus. 5 Dr. Isaac Ott. Dr. L. Webster Fox. Dr. W. Frank Haehnlen. Dr. W. E. Hughes. Dr. W. Easterly Ashton. Dr. Wm. H. Pancoast. Dr. Ernest Laplace. Dr. John V. Shoemaker. Dr. J. M. Anders. STAFF of the Medico-Chirurgical Hospital. PHYSICIANS. James M Anders, M.D., LL.D., John V. Shoemaker, M. D., LL. D , William E. Hughes, M. D., Ph. D. SURGEON. Ernest Laplace, M. D., LL. D. OBSTETRICIANS. W. Frank Haehni.en, M. D., Ph. D., W. S. Stewart, M. I). GYNECOLOGIST. W. Easterly Ashton, M. D. SKIN AND VENEREAL DISEASES. John V. Shoemaker, M. D. OPHTHALMOLOGIST. L. Webster Fox, M D. LARYNGOLOGISTS. Charles E. deM. SaJous, M. I)., Arthur H Cleveland, M. D NEUROLOGIST. Chas. W. Burr, M. I). DISEASES OF CHILDREN. Wm. c. HOLLOPETER, m. d. OTOLOGIST. E. B. Gleason, M. D PATHOLOGIST. Joseph McFarland, M. D. Assistant Hospital Staff. PHYSICIANS. A. E. Roussel, M. D. SURGEON. Benj. V. Shimwell, M. D. E. S. Gans, M. D. GYNECOLOGIST. Waiter V. Woods, M. D. 7 Faculty of the Medico-Chirurgical College. Emeritus. GEORGE E. STUBBS, A.M., M. D. WILLIAM S. STEWART, A. M., M. D. Honorary. *H. EARNEST GOODMAN, M. D. W. B. ATKINSON, A. M., M. D. JOHN V. SHOEMAKER, M. D., LL.D., Professor of Materia Medica, Pharmacology, and Therapeutics, No. 1519 Walnut Street. JAMES M. ANDERS, M. D., Ph.D., LL.D.. Professor of Theory and Practice of Medicine and Clinical Medicine, No. 1605 Walnut Street. ERNEST LAPLACE, M.D., LL.D., Professor of Surgery and Clinical Surgery, No. 1828 South Rittenhouse Square. W. FRANK HAEHNLEN, M. D., Ph. D., Professor of Obstetrics, No. 1616 Walnut Street. W. EASTERLY ASHTON, M. D., Professor of Gynecology, No. 2011 Walnut Street. I.. WEBSTER FOX, M.D., Professor of Ophthalmology, No. 1304 Walnut Street. WILLIAM E. HUGHES, M.D., Ph.D., Professor of Clinical Medicine, No. 3726 Baring Street. ISAAC OTT, A.M., M.D., Professor of Physiology. * Deceased. 8 CHARLES E. deM. SA JOUS, M. D., Dean of the Faculty. SENECA EGBERT, A. M., M. D„ Professor of Hygiene, No. 4814 Springfield Avenue. JOSEPH MCFARLAND, M. D., Professor of Pathology and Bacteriology G. H. MEEKER, B.S., M.S., Professor of Chemistry. CHARLES E. deM. SA JOUS, M.D., Professor of Laryngology, No. 2043 Walnut Street. JOHN C. HEISLER, M.D., Professor of Anatomy, No. 3705 Powelton Avenue. CHARLES E. deM. SAJOUS, M. D , Dean, at the College, 18th and Cherry Sts., Clinical and Assistant Professors. JOHN V. SHOEMAKER, M.D., LL D., Clinical Professor of Diseases of the Skin. W. C. HOLLOPETER, A.M., M. D., Clinical Professor of Children's Diseases. CHARLES W. BURR, A.M., M. D., Clinical Professor of Nervous Diseases. ARTHUR H. CLEVELAND, M. D., Clinical Professor of Laryngology. E. B. GLEASON, M.D., Clinical Professor of Otology. 9 JAS. P. MINN, M.D., Clinical Professor of Orthopaedics. M.D., Clinical Professor of Genito-Urinary Surgery. BENJAMIN T. SHIM WELL, M. D., Assistant Professor of Surgery. ALBERT E. ROUSSEL, A. M., M. D., Adjunct Professor of Practice and Clinical Medicine. SPENCER MORRIS, Ph.D., M. D., Adjunct Professor of Medical Jurisprudence. W. BLAIR STEWART, A.M., M. D., Assistant Professor of Pharmacology and Physiological Action of Drugs. HENRY FISHER, Ph.G., M. D , Assistant Professor of Materia Medica and Pharmacy. Lecturers. SPENCER MORRIS, M. D., Lecturer on Differential Diagnosis. WM. WALLACE, M. D., Demonstrator of Anatomy. EMANUEL S. GANS, M. D., Lecturer on Skin Diseases. MICHAEL O'HARA, Jr., M. D., Lecturer on Minor Surgery and Bandaging. HOWARD S. ANDERS, A. M., M. D., Lecturer and Clinical Instructor on Physical Diagnosis. I. NEWTON SNIVELY, A. M.,M.D., Lecturer on Physical Diagnosis. 10 THOMAS T. BLAND, M. D., Lecturer on Anatony. W. NEWBOLD WATSON, M. D., Demonstrator of Histology. GEORGE M. BOYD, M. D., Demonstrator of Obstetrics. WALTER V. WOODS, M. D., Demonstrator in Gynecology. C. H GUBBINS, Ph. G., M. D., Instructor in Materia Medica and Pharmacy. J. F. HAMILTON, M. D Instructor in Surgery. MATTHEW BEARDWOOD, Jr., A. M., M. D., Instructor in Chemistry. J. G. HERSCHELROTH, M. D , Instructor in Medicine. J. THOMPSON SCHELL, M. D., Instructor in Obstetrics. E. F. KAMERLY, Jr,, M. D., Instructor in Ophthalmology. F. K. BROWN, M. D., Instructor in Ophthalmoscopy. ISIDORE M. KOCH, M. D., Instructor in Skin and Venereal Diseases. ALEXANDER RAMSAY, M. D., Instructor in Children's Diseases. H. D. MARCUS, M. D., Instructor in Materia Medica and Therapeutics. Charles l. furbush, m. d., Demonstrator of Histology. 11 the; exterior of the clinical amphitheatre. The Clinical Amphitheatre of the Medico-Chirurgical Hospital. To aftbrd opportunities of clinical instruction to large num- bers of medical students, and to surround its surgical operations with conditions thoroughly aseptic and in accord with the most advanced scientific thought, the Board of Trustees of the Medico Chirur- gical Hospital has caused to be erected the clinical amphitheatre and operating rooms, which form the subject ot this monograph. The building is adjacent to the Hospital on the north side of Cherry St., east of Eighteenth St., Philadelphia. It is believed to be the most excellent as well as the largest clinical amphi- theatre which has yet been erected either in the United States or Europe. Its construction is fire-proof throughout, the floor being of concrete arches on iron beams. Its floors and wainscots are throughout of marble. All of the plastering is finished in enamel, and wood work has been used only in the doors and windows. Its seating capacity is about five hundred. The planning and execution of the work have been in the hands of Messrs. Frank Miles Day and Brother, Architects, who have been directed by a Building Committee consisting of Ernest Laplace, M. D., Chairman, W. Easterly Ashton, M. D., and James M. Anders, M. D. The exterior of the building is in the style of the Renaissance. A high base of Hummelstown brown stone carries the super- structure which is of Pompeian bricks and terra cotta. The chief features of the front are three large arched windows, below which are marble tablets bearing the names of epoch-making physicians and surgeons, beginning with Hippocrates, Galen and Celsus and extending to Pasteur, Koch and Lister. The names of Sims, Agnew, Goodell, Pancoast, Gross, and other American con- tributors to medical science, are found upon the list. 13 THE MAIN VESTIBULE. Access to the Building. The building is entered from Cherry street, by students, through the main vestibule, which, not being considered as within the aseptic limit, has been finished in quartered white oak. From the vestibule, which is level with the basement, two stairways ascend passing the main floor, and reaching the second whence, four stairways give access to the top of the Amphitheatre. The main floor is directly in connection with the general hospital to the east and with the maternity and children's hospital to the west. The Operating Floor. On examining the plan of this floor upon the next page it will be seen that the central point around which are assembled all the secondary rooms, is the operating space at the foot of the Amphitheatre, a description of which is subsequently given. Adjoining the operating space is a room in which the surgi- cal instruments used by the operators are kept in cases of special construction; another in which the instruments are cleaned after use and a third, containing a modern pressure sterilized apparatus where all instruments, water and dressing are sterilized under 15 pounds steam pressure, giving a temperature 244 degrees of heat. The operating space is connected with these rooms and with the main corridor by four great marble doors, each a single slab, weighing over five hundred pounds, yet poised so easily on con- cealed hinges, as to need but little force to open it, and closing noiselessly, without a touch. To complete the preparation for an operation, many other rooms are needed, these are arranged upon the main corridor sur- rounding the operating space and beneath the Amphitheatre. Among these are the waiting room for visiting physicians and 15 PLAN OF THE OPERATING FLOOR. surgeons, the waiting room and examination room for patients, an etherizing room, a room for the preparation of bandages, with an electrical winding apparatus, and a room for the storage of prepared dressings. There is a general lavatory and dressing room in which the operator and his assistants will assume the garb suitable for an operation and resume their own clothes after it. This room is fitted with a series of lockers, in which surgeons, to whom are not apportioned special rooms, will keep their operating garments On the first floor there is also a room for the department of Clinical Medicine. Although all demonstrations before large classes will be given in the Amphitheatre, nevertheless, many of the most im- portant cases must necessarily be treated in private, and for these a series of separate rooms is provided. The Special Operating Rooms are arranged along the north side of the building. One of these is for Ophthalmology, another for Gynecology, a third for General Surgery, and a fourth for Medical and Electrical Operations. These rooms are adjoined by special lavatories and a steriliz- ing room. Each of the special operating rooms is about twenty feet square and is wainscoated to the ceiling with slabs of marble. Each room has a flood of light from skylights both above and to the north. A view of the interior of one of the special operating rooms is given near the end of this monograph. Let us return now to the central operating space in order that the Amphitheatre may be examined. 17 THE INTERIOR OF THE CLINICAL AMPHITHEATRE. The Amphitheatre is the most noteworthy feature of the building. In it both medi- cal and surgical clinics are held. The form of seating is that of a real Amphitheatre, the rows of seats extending entirely around the central space and rising abruptly from it, tier on tier. Each student has a separate place, consisting of a wooden seat and small back, the only wood work in the Amphitheatre. Below the seats is a vast cone of sheet iron work, finished in enamel and encircled at the top by a water pipe provided with innumerable jets from which a sheet of water is caused to flow down the cone to outlets at its base. After every clinic the cone will be flooded and all traces of the presence of an audience removed. In transverse section the tiers of seats are not tangent to a straight line, but rise more rapidly the greater the distance from the operation. The lines of vision have been so arranged that each student has a view of the operation entirely uninter- rupted by others in front of him. The pitch of the seats is there- for necessarily very steep.. The Amphitheatre is illuminated by an enormous skylight in the ceiling and to the north. Beneath the skylight is the Central Operating Space where lecturer, attendants, nurses and patient will appear. This space has a floor of slabs of gray Knox- ville marble and a high wainscot of white Italian marble. A curved marble bench raised on a step affords room for visiting physicians or distinguished guests. The Amphitheatre is made bright by the many polished brass railings, that render safe the descent of the steep steps by which students reach their places. 19 PLAN OF THE SECOND FLOOR. Skotographic and Historian's Rooms. The cone of the Amphitheatre of course widens as it increases in height. On the second floor there remains therefore but little room beneath it, except for the broad corridors traversed by students in ascending to their places. There is however, a room for the Historian who will keep accurate records of all cases treated in the building, and a Skotographic room equipped with a most complete outfit for making examinations by the aid of Roentgen rays. Tn the basement there is a dark room especially constructed for developing negatives. The Heating and Ventilating Systems. The heating and ventilating systems for this building were designed by Messrs. Francis Brothers & Jellett, consulting engi- neers to the architects. The matter was studied at length, keep- ing in mind always the number of occupants and use of each room. The system adopted was that of blowers furnishing hot, tempered or cool air, a complete system of exhaust ventilation being introduced to take away the vitiated air. Two systems were introduced, the Amphitheatre proper being treated as a separate problem, both for the supply of hot air and for the removal of vitiated air. The supply of air for both systems is brought from above the roof of the building, through a main air shaft shown on the basement plan. The air enters the main air chamber, is drawn through dust screens arranged with an air washing device, and thence into the blowers themselves. The air washing device is designed for the removal of dust from the air and also for moistening it when the air is unusually dry. The screens are made sectional, so that they may be removed for cleaning. Before entering the blowers, the air 21 PLAN OF SEATING OF AMPHITHEATRE. passes through tempering coils intended to raise the temperature of the air slightly, in chilly weather, so that air delivered to the building through the by-passes, may not enter the rooms abso- lutely cold. These tempering coils are regulated by valves, so that the temperature may be raised or lowered as required. After passing from the main air chamber, through the tempering coils the heating of the building is divided into two separate systems; the first which supplies the Amphitheatre proper may be described as follows: The Air Supply to Amphitheatre. The blower is 110 in. high by 36 in. in width, has a capacity of 18,000 cu. ft. of air per minute. The main Amphitheatre con- tains approximately 75,000 cu. ft. of space to be warmed and ventilated. Its capacity, including all seats and standing room, would be approximately 600 men. This system is designed to furnish 1500 cu. ft. of fresh air per hour per occupant, or a total of 900,000 cu. ft. of air per hour into the Amphitheatre alone. The air is delivered into the room through one hundred and thirty-five cast iron goose neck inlets, and two main registers, close to the operating table, making a total actual area of delivery into the room of approximately 60 sq. ft. It is intended that the air shall be brought in at very low velocities, not exceeding 300 feet. The goose necks are turned down, so as to throw the air close to the cone, to prevent any draft to those on the seats over them and also to get the widest possible distribution of air. They are supplied through a system of ducts, which are carried under the iron framing of the floors, and in the false space over the corridors of the floors below, terminating in a series of large ducts along the basement ceiling, immediately connected with the cas- ing of the heater in front of the blower. 23 PLAN OF BASEMENT, SHOWING HEATING AND VENTILATING APPARATUS. The air is controlled by a damper operated by a Powers system for automatically regulating the temperature. The ther- mostat may be set at any required point. The thermometer in connection with the thermostat is located in the main Amphitheatre. If it is desirable to keep the temperature at any given degree, the thermometer is adjusted to the desired point, and when the temperature reaches this point, in the room, the apparatus is set in motion, the main damper below shutting off the heat and allowing more cool air to come in. This damper is operated by compressed air from a small air pump in the basement connected with the steam system. The operation of the damper is such that the volume of air is never lessened, but the proportion is regulated between the hot air coming from the main heater, and the tempered air coming through the by-pass, as the area of the hot air duct is lessened by the movement of the damper, the dis- charge area from the tempered air duct is increased or the reverse. Between the main damper and the discharge outlet of blower, are located the main heating coils. These are cased in iron, and have a by-pass underneath, so that the main air supply after passing through the tempering coils and through the blower, may be warmed to the higher temperature required or may be diverted and sent through the by-pass under the heater, without this re- heating arrangement, so that at all times, the temperature in the room is controlled by the thermostat. The Thermostat System. The Air Supply to Operating Rooms. The private operating rooms, and other rooms throughout the first floor, are warmed from a second blower already referred to. This blower has a capacity for delivering 5000 cu. ft. of air per minute through the registers into the various rooms, at a velocity not exceeding 400 ft. per minute. This system is designed to make a change of air six times per hour, in all rooms, and four times per hour in all hallways. All the principal rooms have 25 PLAN SHOWING THE DISTRIBUTION OF AIR IN THE AMPHITHEATRE. double flues, one side of the Hue bringing hot air into the room, and the other side tempered air. The register is set across both flues, with a sliding damper located below them, operated by lever handles. By this arrangement the occupants of each room can regulate the temperature in that room to suit their require- ments. Should a high temperature, say 80° be wanted, the tem- pered air may be entirely shut off, and nothing but hot air brought in. The roiom can be quickly cooled again by reversing the damper, shutting off the hot air and admitting the cooler air. A series of ducts from the mouth of the smaller blower to the various flues, is shown on the basement plan, the hot and cold air ducts running side by side, making separate connections through- out. There is no thermostat system in connection with this part of the apparatus, it being the intention that each room shall be regulated to suit its particular needs at any time. The System of Ducts. The ducts throughout are all made of galvanized iron, care being taken to proportion them so that each branch may get its full supply. Special wedge dampers are inserted at the main turns in the piping, so that the amount of air admitted into each branch may be absolutely fixed. After anemometer tests are made of the system, and the necessary supply of air to each branch is determined, these dampers may be locked in position. The hot air ducts are all wrapped with asbestos and canvas to prevent loss of heat in transmission through the basement so as to insure maximum results from the apparatus The ducts are connected to the mouth of the blowers by means of joists of canvas, made in accordion fashion, to prevent vibrations from the machinery being carried through these pipes and ducts to the building, the whole system being designed on a liberal scale, that the results may be accomplished without any forcing. The blowers are driven by direct-connected engines; each blower being inde- pendent of the other. 27 PLAN OF VENTILATING DUCTS IN LOFT. Skylight Coils. In addition to the heating previously described, there are special coils placed along the ribs dividing the glass of the sky- lights over the four private operating rooms, and under the sky- light over the main Amphitheatre. These are intended to pre- vent a deposit of moisture on the glass by condensation, and consequent dripping of water or clouding of the glass. These coils are arranged on the frame work in such a manner as not to shut out the light and to be as inconspicuous as possible. Each skylight coil is separately controlled by valves located in the basement. The System of Ventilation. The ventilation of the buildingis accomplished by an arrange- ment of exhaust ducts, flues, vent shafts, and aspirating coils. The Amphitheatre proper is ventilated entirely from the ceiling there being 12 large ceiling registers, having an area of 36 sq. ft., of actual outlet. These registers are open at all times, there being no valves in them. They are connected through a system of large ducts made of galvanized iron, running through the loft to a central aspirating chamber. This aspirating chamber contains a total of 128 sq. ft., of heating surface, divided into two aspirating coils, separately valved. The main branches connecting from these registers to this aspirating chamber, are controlled by dampers. The chains for operating each are carried to the general lavatory on the first floor convenient to the main Amphitheatre. The damper may be set to be entirely open, partially closed, or entirely closed, indicators being provided to show in which position they are standing at any time. Each of the smaller rooms, is ventilated through separate flues, the private operating 29 THE INTERIOR OF THE AMPHITHEATRE- rooms having two flues ; each of the others one flue. The hallways are also ventilated into flue registers which operate on the ven- tilating flues at both floor and ceiling. Those at the floor are always open and the others have regulating dampers with operating chains with indicators. These flues are all connected in- to a series of ducts running in the false space over first floor corridors, and in the false space over the ceiling of the private operating rooms. They are connected into two main vertical foul air shafts, leading to the loft. In the loft they are again connected with a separate set of exhaust ducts, which lead to the aspirating chamber already referred to as taking the vitiated air from the Amphitheatre. These branches are separately controlled by dampers operated in the same manner as described for the Amphitheatre. The foul air is then allowed to pass through the aspirating coils out through the main ventilator on the roof of the building, which is of ample area to permit of the free exit of the total volume of air at all times. The System of Plumbing Much care has been given to the plumbing. The drainage system throughout is of screw-jointed wrought iron pipe. The wash basins are arranged so that both hot and cold water are turned on or off by a pressure of the foot and the water retained in or released from the basin by similar means. The water supply of the building is taken from the City mains, and connected directly with a Loomis filter of ample capacity to handle the full supply of the building, filtering slowly. Located close to the Loomis filter, is a large filtered water tank into which the filter delivers and from which the house pump takes its supply, delivering into the main storage tank in the loft. Arrangements are made for draining both tanks after filter- 31 ONE OF THE SPECIAL OPERATING ROOMS. ing the water, and also for washing the filter, so that the whole system can be kept in excellent condition at all times, without reference to the condition of the water delivered from the City mains. Overflows and drainage are provided for all work in con- nection with the water supply, and a mercury gauge is located in the basement, to show the level of water in the attic tank. In addition to this gauge there is an overflow valve arranged to start and stop the house service pump automatically by means of the overflow. When the water in the tank reaches the overflow limit, the pump shuts down, and when it falls below this point, the pump starts again, minimizing the amount of attention required. Located close to the filter in the basement, is a hot water generator 3 ft. in diameter by 6 ft. long, built to stand a working pressure of 100 lbs. per square inch. It contains 20 sq.ft of heating surface in seamless drawn brass tubes, its supply being taken from the filtered water tank. This is connected with a system of pipes, so that all parts of the building may be supplied with hot water at a uniform temperature. This is accomplished by the use of a temperature regulator fixed to the steam connection supplying the generator, con- trolled by a thermometer which extends into the water in the generator itself. The temperature of the water automatically admitting or shutting off the steam, so that the water may be kept within 3° to 5° of the temperature at which the regulator is set. 33 Electric Lighting. The building is lighted throughout by electricity, the current being supplied from the general plant in the hospital. The entire wiring of the Amphitheatre building is in iron armor tubing, arranged so that wires may be drawn at any time, without dis- turbing the plaster or without cutting. The Amphitheatre pro- per is lighted principally by the use of incandescent arc lamps, of special design, hung in bowls of ground glass through the ceiling. The lamps themselves being operated and attended to in the loft. Holophone globes are used around the lamps, so as to diffuse the light and minimize shadows. This arrangement gives a very equal distribution of light without a glare. In ad- dition, there are some brackets located around the outer walls, above the line of seats, and also around the operating space. In this space are located two plug outlets, so that bunch lights with reflectors, may be used for special operations requiring additional light at any one point. The lighting of the special operating- rooms is by single lights located in the ceiling, each room hav- ing its own separate switches. Each special operating room also has plug outlets intended for bunch lighting as already described or for surgical use or for operating motors for surgical machinery, or apparatus. The lighting of the halls and minor rooms is in the usual manner, but each room is separately controlled by switches. All the lines in the building- come to central cut-out boards where fuses and main switches are located, so that the entire building can be controlled from these points. The system is designed so as to be at all times accessible, and in case of a burningout of a fuse or any temporary accident, it can be readily located and corrected, without disturb- ing the occupants of the various parts of the building. 34 A lAote of Thanks to the Architects. At a meeting of the Board of Trustees of the Medico-Chirur- gical Hospital, held May 24th, 1897, at which the Architects delivered the Amphitheatre to the Board, the following resolution was unanimously adopted :- Resolved: That in accepting the clinical amphitheatre from the architects, Messrs. Frank Miles Day & Brother, this Board desires to express its entire satisfaction with the building and to tender its thanks to the architects for the deep personal interest which they have taken in planning and designing the building, and for their constant care and vigilance during its construction, and Resolved, That it is the sense of this Board that without such interest and vigilance the highly satisfactory results obtained in the arrangement of the building, in the quality of work- manship, and in the time of completion, would have been impos- sible ; and Resolved, That the Secretary be instructed to have these resolutions printed with a description of the building. 35 CHARLES A. DIXON, ART PRINTER, 908 ARCH ST., PHILA.