February/March 1987 | Volume 38, Issue 2
With its roots in the medically benighted eighteenth century, and its history shaped by the needs of the urban poor, Bellevue has emerged on its 250th anniversary as a world-renowned center of modern medicine
Bellevue Hospital, the oldest hospital in the United States, turned 250 last year. It started as a six-bed ward for the poor, part of an almshouse on lower Broadway, back in 1736, when New York had a population of about nine thousand. As the city grew, Bellevue grew. By 1810 the population of New York was 96,373 and the city fathers were looking for a place to build a real hospital. They purchased a part of what was then Kip’s Bay Farm, between what is now Second Avenue and the East River, around Twenty-eighth Street. The gentleman who originally owned the adjoining land in 1772 had called it Belle View. By 1793 the name had changed to Belle Vue, and in 1825, when the hospital was well established, it was called Bellevue, the name it has had ever since.
By 1870 Bellevue could hold twelve hundred beds and was one of the biggest hospitals in the world. The rich supply of patients had prompted the city fathers to establish Bellevue Hospital Medical College in 1861, so that students could benefit from the wide clinical experience the hospital afforded. It was never the tidiest hospital in the world—how could it be, when its policy was always to accept those patients who could with some justice be called the dregs of humanity? At times it was so loaded with victims of typhus, cholera, and yellow fever that, within minutes of a patient’s death, the body was in a coffin and a new patient in the bed. The record shows that on April 20, 1818, a certain Job Young lay grievously ill, obviously about to die of typhus. When he had, supposedly, expired, his body immediately was loaded into a nearby coffin. A half hour later, several people, wandering through a corridor where coffins were stacked, heard a groan emanating from one of the coffins. A hatchet was used to free Mr. Young, who was, indeed, still alive, and he was reassigned to a bed. Valiant attempts were then made to keep him going, but “he lived an hour and a half longer and returned to his narrow house.” This led to one of many subsequent reforms of medical practices in Bellevue: “It was ordered that thereafter no body should be removed until the physicians had first pronounced the person dead.”
Between 1827 and 1847 mortality rates at Bellevue averaged 20 percent, with a high in one year of 33 percent. When William Stewart Halsted—who devised the residency training program that is still the basis for surgical training everywhere in the world—was an attending surgeon at Bellevue (1883–87), he often operated in a tent set up behind the hospital, because he considered the hospital too filthy for his patients. (Incidentally, while at Bellevue, experimenting with cocaine as an anesthetic, Halsted also became a cocaine addict, an addiction he eventually conquered.) In 1888 Halsted moved to Johns Hopkins Hospital, where he had a long and distinguished career. In the United States he is still considered the father of modern surgery.
In 1897 the medical-school part of Bellevue was destroyed by fire. Between 1906 and 1939 the hospital was rebuilt a bit at a time, since it wasn’t feasible to shut down a section completely while its replacement was being added. The great firm of McKim, Mead & White was the prime architect. By the 1950s Bellevue stretched from Twenty-fifth to Thirtieth streets on First Avenue, with the nurses’ residence and school at the south end and the morgue and pathology building and the psychiatric wards at the other. The various wings of the main hospital were all more or less attached to each other, with the A and B buildings (the medical wards) at the south end and the L and M buildings (the surgical wards built in 1913) at the north end. Wards C through K were aligned in sequence and housed neurology, pediatrics, orthopedics, genitourinary—all the subspecialties one would expect to find in a major hospital.
In 1953, when—fresh from Tufts medical school—I began my residency at Bellevue, three medical schools were closely affiliated with the hospital: Columbia, Cornell, and NYU. There was also a fourth division—Post-Graduate—established for those doctors who had been out in practice and wanted to return for specialty training. Each division had approximately 125 medical beds and 100 surgical beds, and the subspecialty divisions were distributed in more or less random fashion, though NYU, Cornell, and Columbia controlled the lion’s share of these divisions. Cornell, which was the division to which I had applied and been accepted (each medical school was responsible for recruiting its own house staff), had a genitourinary division and neurological and neurosurgery divisions. NYU controlled pediatrics and orthopedics.
Columbia ran the tubercular wards. Between 1908 and 1938 some TB patients had their beds on a boat; the first boat had once been part of the fleet of Staten Island ferries, and it was tied to a dock in the East River, just behind the F and G wards. For that era it was an eminently sensible arrangement. The basic treatment for TB until the Second World War was fresh air and rest, and that was much easier to find on a boat on the East River than in the main hospital itself. With the advent of the antibiotic treatment of TB, the boat was taken out of use and all TB patients were returned to the main hospital.
If, when I first moved into Bellevue, they had told me that the hospital as it stood had originally been built in 1736 and had been minimally improved since that time, I would have believed them; it looked that decrepit partly because what was then the main hospital building had certain oddities of construction, added over the course of thirty years. The administration section, for example, which was more or less in the middle of the front of the main building, was about four steps lower than the adjacent wing. The house-staff quarters, which were on the upper floors of the administrative building, connected, of course, with the wings on either side. But, depending on what floor your room was on, you might have to walk up or down three or four steps to get to the next wing. Nothing terribly difficult; just a bit strange.
The surgical wards, which were to be my home base over the next seven years, were still very much like the wards one sees in photographs of Victorian hospitals. They were wide open, just rows of beds on either side and two rows of beds head to head in the center, with about forty beds to each ward. There was a little green metallic stand near each bed, where patients could keep soap, a toothbrush, and other personal items.
Privacy was nonexistent. The head nurse could sit at her desk at the front of the ward and see all the patients at a glance—a very useful arrangement, particularly on the evening and night shifts, when there might be only one nurse to a ward. The wards in the L and M buildings looked out on the East River, so at least the view was decent. If a patient needed privacy, say for a physical examination, screens were moved into place around the bed. This was also done when it was decided that a patient was about to die. Privacy was afforded to the dying not only because it seemed the proper thing to do, but also because over the years the house staff had discovered that if patients happened to view the final moments of someone who had recently undergone surgery, one—or even several—of our preoperative patients might decide they preferred to live with their problems and sign out AOR (Assuming Own Responsibility), absolving the medical staff of legal responsibility. We didn’t want these patients to leave until they had had their operations.
Every resident, in 1953, was expected to consider Bellevue home for the duration of his or her employment. We were each assigned a room that contained a bed, a chair, a desk and, most importantly, a telephone. The house-staff dining room was open for three free meals a day, plus an extra meal between 11:00 P.M. and 1:00 A.M. On some divisions a resident might be on call only every third night, but in my surgical division the call schedule was every other night and every other weekend, plus, of course, 7:00 A.M. until 6:00 P.M. on weekdays and 7:00 A.M. until noon on Saturdays. We were on duty Tuesday, Thursday, and Friday nights one week; Monday, Wednesday, Saturday, and Sunday the next. Weekends off duty ran from noon on Saturday until 7:00 A.M. on Monday. Actually, the Tuesday-Thursday-Friday weeks were generally the more wearing of the two shifts, because on Saturday and Sunday there was no elective surgery. If you’d had a busy night, you generally could catch some sleep during the day. In any case, along with three or four meals a day, your room, and your uniforms, you were also paid sixty-five dollars a month to do with what you chose. Even in 1953, sixty-five dollars a month was not a princely sum.
In that year, unlike the situation now, there were far more residencies available nationwide than there were medical-school graduates to fill them. Many hospitals offered more money, less demanding schedules, and good training and supervision as well. Why, then, did I and so many others choose Bellevue?
To put it succinctly, for the challenge. Bellevue then was, even by the usual big-city hospital standards, horrendous. Like most residents, I didn’t know much about city politics, but I knew from my preliminary visit for an interview that Bellevue had to be grossly underfunded. Nobody walked, not the nurses, not the aides, certainly not the doctors; everyone sort of half-trotted. You could tell at a glance that there was too much for everyone to do and too little time to do it.
Even the chief resident of the division—who, one would expect, might get more sleep than the underlings—looked like the wrath of God, with bags under his eyes and a white uniform going to gray as he sat drinking a cup of coffee in the little kitchen just off the patient ward. He treated me nicely, expressed the hope that I would elect to intern there, but made it clear that I should only make the commitment if I was prepared to work my ass off. My surgical division accepted only six residents a year, but there was enough work for twelve. They wanted no one unwilling to give his all for Bellevue. (At that time women were still rare in medicine, and extremely rare in surgery. All that has, of course, now changed.)
The second obvious challenge was the patients. In these open wards the general policy was to put the sickest patients at the front of the ward, nearest the nurse’s desk, so they would get the closest supervision. I looked into the division’s three surgical wards, and it was immediately obvious that at Bellevue a sick patient was one who would be considered critical, if not hopeless, in most hospitals. All the patients near the nurse’s station, and extending for some distance back, had tubes running in or out of most orifices, and all had the appearance of the chronically ill and malnourished recently felled by an acute illness. Among Bellevue patients, malnutrition was endemic, and it was the rare patient who didn’t have two or three diseases to complicate whatever major catastrophe had precipitated his admission.
The clincher was the fact that in those days Bellevue was truly a house-staff hospital. The word of the chief resident, in his fifth or sixth year of training, was law. Officially we had a director—a professor of surgery from Cornell—who visited the hospital for about two hours on Thursday when we held our surgical conference. During my last three years at Bellevue, he also made rounds between 6:00 and 7:00 P.M. on most Monday nights. The absence of a full-time director (to say nothing of the full-time staff doctors that most teaching hospitals now have) guaranteed that residents could take as much personal responsibility for patient care as they were capable of handling. Woe unto the resident who overestimated his capability; the wrath of the chief resident, who was ultimately responsible to the director, could be devastating. But within those boundaries, opportunities to provide medical care were limitless. Few great hospitals offered as much opportunity and challenge to the eager, young, recently graduated medical student.
There can be no question that in 1953, in New York City, Bellevue was the hospital of last resort. Remember that Medicare and Medicaid didn’t exist until 1965. Bellevue, and other city hospitals, were the places where the poor and the elderly came to get their care.
At any other city hospital, if the beds were full and an ambulance showed up with a desperately ill patient, the resident could write “No beds” on the admission slip and send the patient on to Bellevue. At Bellevue you weren’t allowed to write “No beds.” When a patient arrived, if he needed hospital care, he stayed. You either stole a bed from another ward or you built one out of spare parts that were tucked away in closets. No one was ever turned away from Bellevue.
All through my stay, Bellevue was a bit behind the times, to put it kindly. In 1955 New York had a record-breaking heat wave. No part of Bellevue was airconditioned, so when the operating rooms (ORs) got above a certain temperature, we had to cancel all but emergency and cancer surgery. We residents hated that because it meant “our” operations—hemorrhoids, varicose veins, and hernias—were eliminated. (The ORs were air-conditioned in 1957.)
There was also a severe water shortage in New York in that summer. All over Bellevue there were pipes that leaked and faucets that constantly dripped. Did anyone fix these, to save water? Of course not. It was easier just to take the pitchers of water off the tables in the doctors’ dining room.
During my stint at the hospital, we had some elevators that had never been known to work properly. Instead of fixing the buzzers, for example, signs that said “Push down for up” hung on the call-board for seven years. We residents rarely waited for an elevator unless we were going up more than four flights. We never took a down elevator.
In a hospital with twenty-five hundred beds, most of them filled most of the time, there was no page system. Every resident made certain that the head nurse or the clerk on the ward to which he was assigned knew where he was at all times.
Meanwhile, X rays were constantly being lost; or, if they proved to be interesting, stolen by the X-ray residents for their future teaching files. At Bellevue, finding X rays, or the chart from a patient’s previous admission, was a feat to challenge the skills of the most astute private eye. The resident who had a knack for this was almost guaranteed to be reappointed the next year.
There was never enough equipment on the wards. As a surgical resident I learned to keep a pair of bandage scissors tied by a rope to my belt. This was a trick I had picked up when, as a medical student, I had spent two months on the surgical wards at Boston City Hospital, an institution, by the way, every bit as challenging as Bellevue.
The syringes we used for drawing blood were not plastic and disposable, as they have been for the last several years; they were made of glass and were supposed to be sterilized after each use. But at Bellevue there were never enough syringes to use a different one on each patient; and even among the syringes we had, roughly half worked poorly or not at all. As a consequence, when a resident found a syringe that worked well, he might use it on a dozen or more patients in a single morning, and if it was still working well, he’d hide it away to use the next day. Sometimes “hiding it away” meant simply sticking it in his pocket until time to draw blood the next morning. One good syringe might serve for a week. Such behavior, in 1987, would bring the wrath of the director down on the resident’s head—it was a terrible breach of sterile technique—but in 1953 you learned to make whatever accommodations were necessary to get the job done. If you learned nothing else at Bellevue, you learned expediency.
There were never enough dressings, tape, rubber gloves, and ointments for all the patients who needed them. We did the best we could with what we had. We compensated for the lack of equipment by working harder. We took pride in seeing to it that, despite all the physical and mechanical handicaps Bellevue presented, no patient went without proper care. Maybe we couldn’t match the elaborate equipment that Presbyterian and New York hospitals had to offer, but, by God, we residents, nurses, and aides saw to it that our patients got the best personal care available anywhere. There was an esprit de corps at Bellevue that I haven’t seen matched since I last walked out of there on June 30,1960. I love that damned hospital; and so, I believe, does virtually every resident who has ever been part of it.
Strangely—or perhaps it isn’t so strange—in the twenty-six years since I left Bellevue, my formal training completed, I’ve never been back. I’ve revisited New York dozens of times, but I’ve never felt I belonged any longer at Bellevue. It’s a place to work and study and train, and when you belong to Bellevue it owns you, body and soul. But once the umbilical cord is severed, someone else takes your place. Residency training eventually ends (when you’re going through it, it often seems the end will never arrive), but Bellevue goes on forever. Two hundred and fifty years so far, and still going strong.
In 1966 Cornell and Columbia agreed to break connections with Bellevue; it’s now all NYU. The new, completely upto-date Bellevue opened in 1973—outpatient first, then (1975) inpatient, finally (1985) the psychiatric division. There were twenty-five hundred beds in 1953; now, as in most hospitals, there are fewer—twelve hundred in all. And, I’ve been told, everything is up to date, first class, the best available. Bellevue has been designated as a trauma center, a limb-replant center, a heart station, and a head and spinal-cord injury center—a veritable medical mecca. Lorinda Klein, who works on the Bellevue History Project, tells me that because of its facilities, experience, and superb staff, Bellevue is the hospital to which the President of the United States would be brought if he should need urgent hospital care during a visit to New York City. You can’t get any better than that.
At the same time, just so it doesn’t ever forget its origins, the corridors of Bellevue are still filled with the “wretched refuse” of the city. The poor and neglected of earlier times are replaced by their present-day counterparts. From drug addicts to AIDS victims, Bellevue embraces them all. Someone has to. Happy Birthday, Bellevue, baby.