Halsted went on to a distinguished career at Hopkins. Some consider him the most influential American surgeon of his generation, on par with previous luminaries like Valentine Mott. With Welch opening doors, Halsted soon became an associate professor of surgery and then surgeon-in-chief at the Johns Hopkins Hospital, leading the way in areas ranging from gallstone removal to suturing techniques to breast cancer. His radical mastectomy is perhaps his best-known and most controversial legacy.
Halsted also remained a strong voice for Germ Theory and antiseptic surgery. And his demanding methods led to another breakthrough in an unintended way. Shortly after arriving at Hopkins, Halsted found himself attracted to his scrub nurse, Caroline Hampton, who complained about the constant rashes on her hands and forearms caused by the harsh chemicals Halsted employed as disinfectants. To resolve this, Halsted met with representatives of the Goodyear Rubber Company to design a set of sterile surgical gloves that would become standard fare in operating rooms across the country. He also married Caroline Hampton.
What Halsted couldn’t resolve, however, was his dependence on drugs. His daily routine in Baltimore would include three grains of cocaine, often supplemented by morphine, and he’d sometimes disappear for a week or two, enduring what one historian has called “a life of controlled addiction.” William Welch rarely mentioned the subject, and never related the full scope of the problem. “As long as he lived he would occasionally have a relapse and go back to the drug,” Welch supposedly told a confidant after Halsted had died. “He would always go out of town for this and when he returned he could come to me, very contrite and apologetic, to confess.” It was the price that Johns Hopkins silently paid to have the brilliant Halsted around.
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At Bellevue, meanwhile, the well-financed Carnegie Laboratory had become a world leader in bacteriology and public health. Led by Frederic Dennis and Hermann Biggs, its research penetrated deep into disciplines like surgery, where change was needed most. Indeed, Dennis developed the antiseptic routine to guide each operation at Bellevue: “The surgeon scrubs his forearms and hands for five minutes with a sterile brush and hot water and tinctures of green soap. Fingernails are cleaned with a sterile orange stick, then hands are rubbed with lime and soda for three minutes and then rinsed in sterile water. They are then immersed in a 1-3,000 bichloride solution of mercury for two or three minutes, and finally rinsed in a saline solution.”
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Surprisingly, one of the best examples of the antiseptic revolution would remain hidden from public view. Bellevue physicians already had treated two stricken presidents—Lincoln in 1865 and Garfield in 1881. (Moreover, Bellevue’s Fordyce Barker had warned former president Grant to have his throat checked for a possible malignancy, which turned out to be fatal.) And it happened again, in 1893, under circumstances so delicate that the incident went untold for the next twenty-four years, when one of the attending surgeons broke his silence in a spectacular confession in The Saturday Evening Post.
The president was Grover Cleveland, a hard-drinking, cigar-smoking bear of a man who stood five feet eleven inches tall and weighed somewhere north of 250 pounds. Noticing a rough patch near the roof of his mouth, Cleveland had alerted his personal physician, Bellevue’s Joseph Bryant, who sent a piece of the “ulcerative lesion” to pathologists at the Army Medical Museum. When the result came back malignant—confirmed by none other than William Welch—an immediate operation was prescribed. But Cleveland resisted—not out of fear or denial, but because he worried, with good reason, that the news would alarm a nation already enduring one of the worst economic depressions in its history. Absolute secrecy was required for the procedure, which ruled out a hospital or even the White House, where the coming and going of surgeons would surely be noticed.
Dr. Bryant took charge. A former student of Stephen Smith’s, he had spent decades teaching surgery at Bellevue Hospital Medical College. His professional life had closely mirrored the battle over antisepsis, with Bryant reluctantly accepting the ways of Joseph Lister. Upon learning of Cleveland’s biopsy, Bryant put together a six-man surgical team that included two Bellevue colleagues—Dr. John Erdmann, a trusted assistant, and Dr. Edward Janeway, a brilliant diagnostician. Erdmann would help perform the operation, while Janeway would monitor the vital signs. President Cleveland suggested that the operation take place aboard the luxury yacht Oneida, owned by his friend Commodore Elias Benedict, a New York banker. And he insisted there be no telltale changes to his face—meaning no external incisions and no disappearing mustache.
On the morning of July 1, 1893, the Oneida sailed up the East River toward Long Island Sound. “So careful were we to elude observation,” wrote one of the physicians, “that Dr. Bryant and all of us who might have been recognized by some of the staff at Bellevue Hospital deserted the deck for the cabin below.” That afternoon, the president had a “gelatinous mass,” along with five teeth, removed in an operation lasting about an hour and a half. The six medical men wore starched white coats and boiled their instruments. They rinsed Cleveland’s mouth with Thiersch’s solution, favored by finicky surgeons like William Halsted. As one team member put it: “Fresh, pure air, disinfected quarters, and skilled doctors all had to be provided lest blood poisoning set in.”
The operation was successful. Tissue samples examined many years later showed a slow-growing form of squamous cell carcinoma common to heavy smokers. Cleveland would die of a heart attack in 1908, his life extended, in no small part, by the bitter legacy of James A. Garfield.
* * *
*1 Whether Hamilton’s optimism was based on his medical judgment, wishful thinking, a desire to calm public opinion, or a combination of these factors is unknown. Garfield’s medical team kept a daily medical log. The notations include July 27: “The President slept sweetly last night….His general condition is improving.” July 30: “The discharge of his pus is satisfactory in quantity and quality.” August 17: “The President’s condition is even better than it was this morning….Two teaspoons full of beef extract have been twice administered by mouth and not rejected. The wound continues to do well.” As late as September, the log spoke of Garfield’s “unusually good night” and “reassuring general condition.” The final notation on September 19 reads: “He awoke complaining of a severe pain above the region of his right heart. He almost immediately became unconscious and ceased to breathe at 10:35.” Complete Medical Record of President Garfield’s Case, Washington, D.C., 1881.
*2 The friendship was severed. Welch would write Dennis a condolence note in 1890 upon the death of his father, and a second note of congratulation upon his election to the Royal College of Surgeons in 1899. There is no record that Dennis responded. On Welch’s seventieth birthday in 1920, however, Dennis sent along his best wishes. Welch was thrilled. “I wish, Fred, that you would come down and stay awhile with me,” he replied. Six years later Dennis did visit Welch during a business trip to Baltimore. “It quite took my breath away to find you waiting for me,” Welch wrote of the encounter. The two maintained a cordial relationship thereafter. Frederic Dennis Folders, William Welch Papers, Chesney Medical Archives, Johns Hopkins University.
12
THE MAD-HOUSE
Reputations can be remarkably immune to change. In 1878, Harper’s New Monthly published a lengthy piece about New York City’s major hospitals. At one end of its spectrum was private, tidy, well-managed New York Hospital, the perennial favorite of social reformers, and recently upgraded to an ornate brick-and-stone building on 15th Street compliments of its generous trustees. The great bulk of its 163 patients were respectable working-class folk, most paying a modest fee to enjoy “the exquisite cleanliness” of its spacious wards. The modern kitchen, the polished maple elevator, the sun-drenched solarium—all reminded the writer of what future hospitals might happily provide for the unfortunates who had no choice but to use one.
At the other end stood Bellevue, a bare-bones receptacle “for the poorest of the poor, the dre
gs of society, the semi-criminal, starving, unwelcome class, who suffer and die unrecognized.” There were no luxuries to be found in this “ponderous dull gray mass of granite,” and that was a good thing, the article explained, because New York already attracted too many foreign paupers, compounding the “hopeless misery” that had once distinguished American cities from the urban cesspools of Europe.
The writer did throw a bone Bellevue’s way. Students and professors from New York City’s leading medical schools could be spotted in every ward and corridor. Following one class through its bedside rounds, the writer marveled at the endless variety of human suffering on display, the professor “explaining the cases and operations [with] so much perspicuity and simplicity that the thickest-headed student would have unimaginable difficulty in not understanding.” Of Bellevue’s limited virtues, the sheer range of afflictions seemed to stand out most.
The writer wasn’t seeking gray areas, just black and white. There was no mention that Bellevue housed many of the nation’s finest medical researchers; that its attending physicians and residents were among the best in the city; that professional nursing had raised the quality of care in the wards; or that, unlike New York Hospital, it didn’t get to pick the patients it cared to treat. When an ambulance arrived with the victim of a robbery, or a trolley accident, or a boiler explosion; when a paddy wagon dropped off an alcoholic suffering from delirium tremens; when the police court sent over an unruly suspect for mental observation—all were taken in.
On one point, at least, the article got it right. Physically, Bellevue was a wreck—a crumbling former almshouse so overcrowded that patients could be seen sleeping on the floor. And so underfunded that a survey of the nation’s hospitals in 1883 found the “cost-per-patient-per day” at Bellevue to be 49 cents—the lowest figure by far in New York City and well behind other metropolitan hospitals like Boston City ($1.24) and Cook County ($1.01).
Worse, the 49-cent figure included supplies routinely pilfered from Bellevue, where staff thievery was a way of life. Like many hospitals of this era, patient recovery depended on generous alcohol use. “Spirits” at Bellevue accounted for about 20 percent of its annual budget, twice the figure for “medicines.” By one estimate, however, barely 5 percent of the beer, brandy, whiskey, and wine actually reached the mouths of the intended. “It is a mighty dry place,” wrote the rarely sarcastic New York Times, noting “the wonderful evaporating power of the atmosphere around Bellevue Hospital.”
Not surprisingly, Harper’s New Monthly paid scant attention to the subject that would come to dominate Bellevue’s standing in the popular mind: its treatment of the insane. There was little reason to bring it up; the connection was still rather vague. Where Harper’s New Monthly had told a lively if familiar tale of poverty and physical neglect, a more sensational piece of journalism, fusing Bellevue to the hidden world of bedlam, was about to change the hospital’s image forever.
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From its earliest times, the city almshouse had kept a small number of “idiots” and “lunatics” isolated in the basement, often in chains. As their numbers grew, however, this segregation disappeared. “The invalid, the aged, the infirm, the vagrant, and half lunatic are [now] confined together, and are allowed the most unrestrained intercourse,” a grand jury reported in the 1840s, calling the situation an affront to “every Christian.”
The solution, as we have seen, involved a small rocky island in the East River. When the Blackwell family had first put the 107-acre property up for sale in 1784, there were no takers. It wasn’t until decades later, as the almshouse complex and the jails reached overflowing, that public officials took notice of the island’s unique potential—uninhabited, surrounded by water, with “a rapid and violent current” to discourage escapes. In 1828, the Common Council purchased Blackwell’s Island—now called Roosevelt Island—for a handsome $32,000. The following decades would see the construction of a new almshouse, an orphanage, a prison, and a fever hospital. But the island’s grandest structure was a lunatic asylum containing two four-story wings connected by a five-story rotunda of blue-gray stone known as the Octagon.
Bellevue in these years would continue to house a pavilion for the insane. But its role was limited to examining those brought in for observation and then deciding whether to release them or send them on to Blackwell’s Island. These examinations were done quickly; mental patients now remained at Bellevue for a month or less, their fate decided by a young, untrained house staff (interns and residents) acting on little beyond their intuition.
Among the early visitors to Blackwell’s was Charles Dickens, on a grand tour of America’s public institutions. While impressed by the Octagon’s size, he could hardly wait to leave. “The moping idiot, cowering down with long, disheveled hair; the gibbering maniac, with his hideous laugh and pointed finger; the vacant eyes, the fierce wild face, the gloomy picking of the hands and lips, and munching of the nails; they were all without disguise, in their naked ugliness and horror.” Dickens declined to visit the wards where “the violent were kept under restraint,” claiming he’d seen quite enough. “I never felt such deep disgust and measureless contempt,” he wrote, “as when I crossed the threshold of this madhouse.”
There’d be few other visitors in the coming years. The press showed little interest, running occasional stories about the harmless delusions of the patients, like the one who claimed to be the king of Scotland or the sister of the pope. And every so often, a reporter would profile the asylum’s longest-tenured inmate, a woman who insisted she was the widow of President James Buchanan and the mother of his children, all of whom were cats. “I had the honor of stroking the back of the president’s oldest son,” read one such account, “who purred as though his sire had no political difficulties to disturb his repose.”
Each year, the asylum superintendent would issue a report complaining of the crowded conditions and his inadequate budget, yet filled with descriptions of happy patients “planting vegetables” and “learning to play instruments.” The reports sent a jarring mixed message—and almost certainly went unread. In the early 1880s, a superintendent candidly admitted that one of his main accomplishments lay in keeping the asylum out of the news.
But not for long.
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When Joseph Pulitzer bought the New York World from the robber baron financier Jay Gould in 1883, the paper was in trouble. Deeply in debt, with barely fifteen thousand readers, it ran well behind competitors like the Times, Tribune, and Sun. Having made his publishing mark in the heavily immigrant city of St. Louis, Pulitzer had a good feel for what could work in New York. The World quickly found its niche as the voice of the laboring classes, with lurid stories, vivid graphics, and simple words. It created the city’s first sports section and ran splashy headlines—“FRENCH SCIENTIST AND EXPLORER DISCOVERS A RACE OF SAVAGES WITH WELL-DEVELOPED TAILS” being a prime example. A master at mobilizing public opinion for causes that benefited both his newspaper and the city, Pulitzer put the World on solid footing with a campaign to finance a pedestal for the Statue of Liberty, which had just arrived from France. “We must raise the money,” he thundered. “The World is the people’s paper, and now it appeals to the people to come forward….Let us not wait for the millionaires to give us the money.” The campaign caught fire in New York’s immigrant communities, anxious to honor their adopted land. More than 125,000 donors responded, each receiving a mention in the World no matter how small the gift. The Statue of Liberty got its pedestal and the World shot up to first place in reader circulation.
Pulitzer fancied himself a “muckraker.” Having exposed all sorts of corruption in St. Louis, he expected to find more of the same in New York City, especially scandals involving the abuse and fleecing of the poorer classes. The World relied heavily on undercover work—some called it the “new journalism”—in which the newspaper planted a reporter inside a factory, a politician’s office, or a public institution to get the “real” story. An entire generation
of writers would come to prominence through these sensational exposés—none more daring than Elizabeth Jane Cochran, known to the public as Nellie Bly (pseudonyms for women writers being quite common at the time).
Arriving in 1887 from Pittsburgh, where she’d covered debutante balls and flower shows for the local newspaper, Bly literally begged her way into a job at the World. A handful of women, led by the iconic Ida Tarbell, were now doing spirited journalism, and the World was looking to expand the undercover reporting that had become its trademark. Bly, for her part, proved fearless and inventive. Before long, she was posing as an unwed mother to penetrate a baby-buying ring and getting herself arrested to check out the city jail. In 1889, inspired by the Jules Verne novel Around the World in Eighty Days, Bly would circle the globe with the aid of Pulitzer’s wealthy friends, beating Verne’s “record” by more than a week. But her first major story for the World was probably her most important, appearing in two lengthy installments and then as a book titled Ten Days in a Mad-House.
Contrary to most accounts, it wasn’t Bly’s idea. At her job interview, she spoke of exposing the dangers of immigrant travel to America, but the editor wanted something bolder. His plan, Bly recalled, was to “have [me] committed to one of the asylums for the insane in New York, with a view to writing a plain and unvarnished narrative of the treatment of the patients.”
Though “plain” and “unvarnished” weren’t exactly hallmarks of the World’s reporting at the time, she jumped at the chance. More important, Pulitzer wanted the story done. The World had recently run some editorials about the rumored mistreatment of patients on Blackwell’s Island. What it needed was confirmation from a source planted inside.
Bly was given an assumed name she could easily answer to—Nellie Brown. Her editor cleared the caper with a friend in the district attorney’s office so she wouldn’t be prosecuted for entering a city institution under false pretenses. After spending several hours in front of a mirror “practicing to be a lunatic,” Bly checked into a boardinghouse for young women and behaved so oddly that she was carted off to police court, where the judge ordered her taken to Bellevue’s Insane Pavilion for observation. Psychiatry in the 1880s had yet to become a specialty; the young doctors in charge received no training. Their job was to separate the moderately disturbed from those requiring “further attention” on Blackwell’s Island—a subjective process, to be sure. Bly spent two days at the Insane Pavilion pretending to hear voices and act “deranged.” She obviously performed well. The staff declared her “undoubtedly insane.” And that earned her a ferry ride to the Octagon.
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