The need was obvious. Beginning in the 1890s, New York had witnessed a surge of new immigrants—most coming from parts of Europe with few connections to the United States, and many in need of acute medical care. In the past, improvements at Bellevue had followed a distinct pattern: heavy immigration accompanied by an epidemic of some sort, cholera and typhus being prime examples. And it happened once more around 1900, the offender this time being tuberculosis. Also known as phthisis and consumption, TB wasn’t new to the city. In fact, it had been the leading infectious killer in New York for generations, though its numbers had fallen since the discovery of the tubercle bacillus by Germany’s Robert Koch in 1884 and the strict sanitary measures put in place by public health officials. But tuberculosis now appeared to be making a comeback—many blaming the new immigrants and calling it by names like “tailor’s disease” after newly arrived Jews working in the city’s slum-ridden sweatshops.
As usual, Bellevue bore the brunt of it. The problem, said Dr. John Brannon, chairman of the hospital’s Board of Trustees, was that most immigrants suffering from tuberculosis had been admitted for another reason—an accident, a pregnancy, an alcoholic stupor. Since Bellevue had no quarantine facilities beyond two jam-packed chest wards, one male, one female, the victims were mixed in with regular patients—coughing, spitting, spreading their germs. Small wonder that twenty of Bellevue’s sixty-five interns had come down with the disease in a single year. “When we consider the number of nurses and physicians who have contracted tuberculosis during their services at our hospital,” a Bellevue doctor complained, “I think we have a conclusive responsibility to eliminate such dangers of infection as far as possible.”
Brannon had a personal stake in this. Having been “cured” of tuberculosis as a young man, he greatly admired the work of Bellevue’s Hermann Biggs, the city’s premier bacteriologist, who had convinced a skeptical medical establishment, or much of it, that TB could be more easily controlled by making it a mandatorily reportable disease. The campaign, opposed by some as an invasion of privacy, led Robert Koch to send Biggs this note of congratulation: “I wish to cite the example of the free American people who of their own free will accepted the limitation of their own liberties for the sake of public health.”
Given the hundreds of TB patients scattered across Bellevue, Brannon expected the new plan to include a separate building for their quarantine and treatment. Meanwhile, by sheer coincidence, a wealthy young doctor named James Alexander Miller had joined Columbia’s First Division at Bellevue, giving him a peek at “how the other half lived”—and it wasn’t pretty. “There was no attempt to give instruction in the sanitary disposal of the sputum,” he wrote of the primitive TB wards. Germs were shooting everywhere, and the “treatment” consisted of a cough mixture laced with morphine and whiskey.
Urged on by Biggs and Brannon, Miller created the Bellevue Chest Service in 1903. His approach in this post–Germ Theory but pre-antibiotic era was rather like Florence Nightingale’s: good food, plenty of rest, lots of fresh air. Miller quarantined his patients, bundled them up in heavy blankets, and propped them on open roofs and balconies for hours at a time. Milk and eggs replaced morphine and whiskey, compliments of a new women’s group called the Auxiliary to Bellevue. In perhaps his most celebrated move, Miller partnered with the auxiliary to buy the Southfield, a retired Staten Island ferryboat. Docked in the East River, it became a fresh air “summer camp” for poor children with “incipient or moderate” tuberculosis.
Supporters of the McKim, Mead & White master plan used examples like the Southfield to show Bellevue’s deep connection to the city. This wasn’t another run-of-the-mill public hospital, they argued; it was a research center, a teaching facility, a beacon of compassionate care. For all its troubles, Bellevue had always served New Yorkers in times of need—its history intertwined with the wars, riots, epidemics, and assorted calamities that had marked the city’s raucous past. Only years earlier, its staff had treated hundreds of victims of the Great Heat Wave of 1896, a ten-day August inferno of record temperatures and eerily still air. “Doctors stripped [one] man and placed him in a large tub filled with as much as half a ton of cracked ice,” a reporter noted. “A thermometer placed in the man’s mouth registered the maximum: 110 degrees. Attendants grabbed large chunks of ice and rubbed the patient’s skin. After ten minutes the man’s temperature dropped three degrees. A few more minutes, and his temperature was back down to a normal 98.6.” Newspapers marveled at the effort.
Then, in the very midst of the master plan discussion, came an unspeakable disaster. An excursion boat, the General Slocum, caught fire in the East River on its way to a church picnic, killing more than a thousand of the 1,358 passengers on board. Bellevue’s entire ambulance corps rushed to the water’s edge carrying staffers and supplies. Survivors filled the wards, and bodies lay stacked in the morgue. For years afterward, stories circulated about the horror and courage of that awful Sunday afternoon. “He dived overboard seventeen times to make rescues and brought a total of 145 bodies to the Bellevue dock aboard his vessel,” read the obituary of a ferryboat captain four decades later, citing the hospital’s steady hand when tragedy struck.
Still, criticism of the master plan was intense. Some saw the site itself as outmoded. Why not move it farther uptown to follow Manhattan’s northward migration? Others grumbled at the expense, which, by current estimates, would equal one third the cost of the entire subway line then under construction from City Hall to the Bronx. Couldn’t improvements be made on a smaller scale? Did a hospital for the poor really need the look of a lavish train station or a fancy college campus?
Under growing pressure the trustees backed off. Their memos to McKim, Mead & White became more critical: Be “less pretentious.” Try “a simpler design.” At last, a firm order came down: “It is the sense of the Trustees that all unnecessary or expensive features be dispensed with.”
A slimmed-down version soon appeared. The gymnasium vanished, along with the tennis courts and swimming pool. The pneumatic tubes were scuttled, and the living quarters scaled back. The ornate touches—save the Corinthian columns, wrought iron railings, and patient balconies—largely disappeared. Cement replaced tile in the bathrooms; the granite finishes gave way to brick. Gone, too, was the most visible symbol of excess. “OMIT DOME and put regular flat roof in [its] place—SAVINGS, $420,000,” read the “REDUCTIONS” memo prepared by the trustees. It was the safest way, they understood, of keeping the Bellevue project alive.
The new plan called for two thousand beds, a third fewer than before. And to spread out the costs, the old buildings would be torn down and replaced over years, not months. In 1910, Bellevue opened the four-hundred-bed medical pavilion, followed two years later by a new pathology building and morgue. Then came the five-hundred-bed surgical pavilion, with its massive operating theater. Not everyone was pleased. The “blandness” of the structures surprised those expecting greater vision from the likes of Stanford White. A planner hired by the city to evaluate the project could barely hide his contempt. The pavilions were oddly spaced, he thought, creating a maze of corridors. The ceilings were too high, the windows too small, the wards too long and narrow. “It is my opinion,” he said, sticking the knife still deeper, “that [comfort] has been sacrificed too much to architectural line, although the architecture of the buildings, in spite of the sacrifice, is somewhat disappointing.”
The price tag, meanwhile, was approaching $20 million, almost twice the original budget, with half the buildings yet to break ground. “It seems a great deal more money than ought to be expended on any one hospital,” griped the New York Times.
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Aesthetics aside, a modern behemoth was taking shape. And it wouldn’t take long to fill the extra beds. Near the end of the nineteenth century, immigration to the United States took a dramatic turn. Until that point, the vast majority of foreigners had come from the British Isles, Germany, and Scandinavia. Between 1890 and 1920, however, a se
ries of major crises, from anti-Semitic pogroms to radical changes in landholding and agriculture, brought a flood of immigrants from Southern and Eastern Europe. The number of foreign-born Italians in the United States rose from 250,000 to 3,339,000 in these decades, while the number of foreign-born Russians (overwhelmingly Jewish) soared from 258,000 to 3,871,000. Many listed New York City as their final destination.
The reaction was not unlike the one that greeted the Irish a half century before. A government study, “The Foreign Immigrant in New York City,” questioned whether any municipality could assimilate so many newcomers holding such alien beliefs. The study’s author wasn’t shy—few were in those days—about the “special traits” of various ethnic groups. Italian children, she wrote, were “fair students, better than the Irish, but not as good as the Hebrews and Germans at book work.” Fortunately, they weren’t a problem in class, despite their limited attention spans, because Italian parents showed “a somewhat terrifying eagerness to add discipline on their own part in the shape of corporal punishment to that already administered by the school.”
Many viewed these immigrants as purveyors of disease. Where the Irish had been accused of bringing cholera and typhus to New York in the 1830s and 1840s, now Jews were suspected of spreading tuberculosis, despite its low incidence in their neighborhoods, while Italians would be blamed for causing the city’s first polio outbreak in 1916. There was no shortage of explanations—biological determinism often heading the list. Steerage passengers from Southern Europe “show a depressing frequency of low foreheads, open mouths, weak chins, poor features, skew faces, small or knobby crania, and backless heads,” wrote the prominent sociologist E. A. Ross. “Such people lack the power to take rational care of themselves; hence their death rate in New York is twice the general death rate and thrice that of the Germans.”
Bellevue naturally mirrored the city’s rapidly changing population. In 1890, foreign-born Irish had comprised 31 percent of the hospital’s admissions, with foreign-born Germans at 11 percent, Italians at 3 percent, and Russians too few to count. (Bellevue didn’t list the ancestry of its American-born patients.) By 1913, the ground had shifted. Foreign-born Irish and German admissions to Bellevue had dropped from 42 percent to 20 percent, while foreign-born Italian and East European admissions had jumped from 4 percent to 12 percent—and were climbing fast.
Close to one third of these foreign-born patients in 1913 were “non-citizens.” What rankled Bellevue officials was the fact that so many of them had come to their hospital within “a day or less” of reaching Manhattan—meaning their “illness” had been overlooked by the steamship operators who brought them over from Europe and the public health doctors who examined them at Ellis Island. For the already overburdened Bellevue staff, treating hundreds of “mandatorily excludible” cases—“idiots, imbeciles, epileptics, alcoholics, those with tuberculosis and dangerous contagious diseases”—would become a routine, if disagreeable, part of the job. And there was no use complaining about it because federal authorities weren’t interested in enforcing the law. In 1913, the Immigration Service rounded up a grand total of seven Bellevue patients for deportation.
The irony, of course, was that Bellevue had never been popular with the groups now pouring through its doors. Previous generations of Jews and Italians had scrupulously avoided the place, viewing it as a death trap and a refuge for the “low Irish.” For years, rumors had abounded in the city’s immigrant neighborhoods about the “black bottle” used at Bellevue to “bump off” patients who “weren’t worth saving.” “The opinion is prevalent…that Bellevue is a school of experiment for the instruction of young surgeons, and that only cases of peculiar novelty are of interest there,” a city health officer explained. “In cases of lingering sickness…they are supposed to hasten the end by administering a fatal dose from the mysterious black bottle.” Or, as immigrant legend had it, “they give you a drink, and that’s the end of you.”
New York’s small Jewish community had long favored Mount Sinai in emergencies, while Italians preferred Roman Catholic Columbus Hospital, where their native tongue was spoken. But times had changed. Private (or “voluntary”) hospitals could no longer handle the sheer volume of foreigners now seeking admission—nor, in some cases, did they want to. At Mount Sinai, officials were quite open about favoring “the better conditioned of people” over the unwashed masses, just off the boats. “In the philanthropic institutions of our aristocratic German Jews you see beautiful offices, desks all decorated, but strict and angry faces,” a recent immigrant complained. “Every poor man is questioned like a criminal, is looked down upon; every unfortunate suffers self-degradation and shivers like a leaf, just as if we were standing before a Russian official.”
Given a choice, many new arrivals preferred Bellevue’s rough egalitarianism to Mount Sinai’s stern condescension. Bellevue asked no questions. It was less judgmental, and a lot closer to the teeming immigrant slums of the Lower East Side—Mount Sinai having moved uptown to better serve its well-heeled patients. The 1890s had seen a sprinkling of Jewish and Italian names in the Bellevue ledgers, an occasional “Isaac Levy, Russia, tailor” or “Guiseppe Amato, Italy, longshoreman” among the scores of Callahans and Kellys. In 1907, a small synagogue opened at Bellevue for “Hebrew worshippers” and a translator was hired to accommodate Yiddish-speaking patients. By 1915, the sprinkling had become a steady stream. A look at Bellevue’s pediatric files that year shows a clear majority of Jewish and Italian names: Julia Cohen, Morris Fink, Solomon Iskowitz, Sam Katz, Joseph Schwartz, Ada Nutelli, Agnes Pellegrino, Dominic Rossi—the list goes on. By 1920, more Jewish and Italian immigrants would be entering Bellevue than any other hospital in the city.
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Bellevue’s growth in these years was stunning. Admissions rose from 6,546 in 1879 to 45,470 by 1920. And Bellevue wasn’t alone. Hospitals throughout the city were expanding, though the reasons owed little to the immigrant explosion or the medical needs of the poor. What had changed—and quite radically—was the public’s negative perception of the hospital itself. Once viewed as a dumping ground for the lower classes, it had begun to attract “respectable” folk long accustomed to being treated at home. The era of the “private” patient had arrived.
The concept wasn’t new. As far back as the 1860s, St. Vincent’s had made a few rooms available for those wanting something more than a ward bed. But it wasn’t until the turn of the century that voluntary hospitals started to build separate quarters for private patients in a serious way. New York Hospital opened a ten-story structure in 1900 with “brass bedsteads, couches, and open fireplaces,” followed quickly by Mount Sinai, its private rooms overlooking Central Park, its charity wards facing the side streets. A survey of New York City hospitals in 1924 showed close to 30 percent of all patients occupying private or semiprivate rooms. The trend has “had a beneficial influence,” the authors noted, because “the hospital [has] ceased to be regarded as exclusively the refuge of the sick poor.”
What, exactly, had made a hospital more appealing to patients in 1910 than it had been in 1880? The most obvious answer is the remarkable impact of science and technology. Surgical operations had become safer, thanks to Pasteur, Semmelweis, and Lister. Trained nurses could sterilize wounds and monitor a patient’s vital signs. Blood and tissue samples could be sent to well-equipped laboratories for examination. The newly discovered X-ray was coming into use. “Today,” a writer observed in Popular Science Monthly, “the patient approaches [the hospital] with…the hope of life rather than the fear of death.”
But well-heeled patients weren’t about to mingle with the charity cases or forgo the luxuries of home. And they no longer had to. A stay at New York Hospital or Mount Sinai might now include a room with fresh-cut flowers and plush Persian rugs. So, too, gourmet meals and full-time nursing care. Even the bathrobes and bedsheets of private patients were color-coded to separate them from the laundry of the hoi polloi. For the privileged few, the hospital
had come to resemble a medical resort, described by the Times as “a hotel for rich invalids.”
There was space for the middle classes as well. Those unable to afford the staggering $40 to $75 a week for princely quarters could find a “semi-private room” or a “pay ward” at a fraction of the price. It wasn’t luxurious, but it did segregate them from the putrid smells and poorer elements they hoped to avoid. The end result was an institution increasingly split by social class, with paying patients getting preferred space and a lion’s share of the resources. One medical journal, sensing that a corner had been turned, implored its readers to step back and search their souls. “In the spirit of fairness and in the name of charity…we ask, ‘Is it right?’ ”
It would be hard to overstate the importance of science, sanitation, and material comfort in creating the modern American hospital. But there was another factor as well. Those who had avoided hospitals in the past normally used a trusted family physician—someone familiar with their needs. Would they now enter a place filled with doctors they didn’t know?
Hospital privileges had long been restricted to those who taught at a medical school and did some clinical research. The rule hadn’t mattered much in the era when hospitals were filled with the lower classes. But the new competition for private patients depended heavily on referrals from family doctors whose wants—and resentments—could no longer be ignored. As one of them fumed: “Why is it that when our patients enter a hospital we must surrender them to self-styled and Lord-knows how appointed professors…who assume ownership and charge of them…in absolute disregard of our rights in the matter?” Opening the hospital door to family doctors no doubt diminished the power of the elite medical practitioner; but keeping them out severely restricted the number of paying patients—a far greater concern.
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