Cholera would return in the coming decades, devastating immigrant neighborhoods and swamping Bellevue’s morgue. In 1849, it killed 5,071 New Yorkers, including 3,250 foreign-born. But over time, in laboratories across Europe, cholera’s secrets would be exposed. In 1854, the British physician John Snow proved that the disease was transmitted not by noxious fumes in the atmosphere, but rather by a specific agent in the water. His diligence in tracing the victims of a single London epidemic—the so-called Ghost Map—would become the model for future studies of infectious disease. Exactly thirty years later, in 1884, the German researcher Robert Koch identified the specific agent as the comma-shaped microorganism Vibrio cholerae, a discovery that helped demolish the Miasma Theory for good.
Some New Yorkers saw cholera as a blessing in disguise. “Those sickened must be cured or die off,” wrote an unforgiving official, “& being chiefly of the very scum of the city, the quicker [their] dispatch the sooner the malady will cease.” For him and his allies, the answer lay in restricting the flow of immigrants to America and quarantining those who did reach its shores.
Others disagreed. The Irish were here to stay, they thought, and not likely to change on their own. Cursing their filth and intemperance, while a natural response, did little to prevent epidemics that put the entire city at risk. A more practical approach was to focus less on the moral failings of these immigrants, which city officials couldn’t effectively control, and more on the environmental causes of disease, which they could. If foul vapors and general filth were the cause of cholera and other epidemic diseases, then why not whitewash the tenements and close down the stinking wells?
Epidemics can be tricky as agents of change. They arrive with frightening force, do their awful damage, and leave as mysteriously as they come. It’s easy to view them as freaks of nature, or divine occurrences, impossible to control. In the case of cholera, however, some valuable lessons would be learned. It was no accident, for example, that Five Points got its first major street cleaning in 1832, exposing the paving stones that lay beneath piles of sludge. Three years later, New Yorkers approved the construction of a forty-one-mile-long aqueduct to bring clean water from the Croton River, north of the city, to holding reservoirs on 42nd Street, where the main branch of the public library stands today, and the Upper West Side, in what is now Central Park. The project, costing $11.5 million and employing four thousand workers, allowed the city to slowly phase out its hodgepodge of contaminated local wells. In 1849, following another deadly cholera outbreak, an ordinance was passed banning swine from New York’s most populated neighborhoods. “Overcoming sometimes violent resistance by impoverished owners, the police flushed five to six thousand pigs out of cellars and garrets and drove an estimated twenty thousand swine north to the upper wards.”
Cholera also exposed the flaws of the Bellevue Establishment. Opened to great acclaim in 1816, it had quickly become an attraction for social reformers like Alexis de Tocqueville, who remained oddly silent about the conditions he saw there but scathing in his review of the banquet thrown to honor him. (The planning, Tocqueville wrote his sister, “represented the infancy of the art: the vegetables and fish before the meat; the oysters for dessert. In a word, complete barbarism.”) What others noted, however, was the ever-growing crush of bodies, which periodic epidemics made worse. Was it wise to mix so many people, with so many different problems, within the same set of walls?
David Hosack had predicted as much: the Bellevue Establishment had failed. Medical care remained captive to the dreary world of the almshouse and the pesthouse, foreclosing better options for the poor. Until things changed—until that link was broken—a true public hospital for New York City seemed all but impossible.
3
THE GREAT EPIDEMIC
In antebellum New York, much like today, wealth played a key role in one’s health care. The rich paid handsomely for the privilege; the poor relied on the charity of others. Yet what neither side fully grasped were the slender distinctions that separated the “best” from the “worst” medical treatment of this era—a time of painfully slow progress in the field. Money may have provided the illusion of proper care, but it did nothing to protect a child from diphtheria, a mother from puerperal fever, or a father from tuberculosis. The medical profession simply lacked the tools to be effective. As the physician-philosopher Lawrence Henderson aptly put it, “a random patient, with a random disease, consulting a doctor at random had no better than a fifty-fifty chance of profiting from the encounter.”
The same went for hospitals. Americans saw little need for them in the early 1800s because what occurred there could be done more safely and comfortably at home. Lacking anesthesia, antisepsis, and X-rays, among other modern essentials, the hospital resembled a poorhouse with a vaguely medical bent. No institutions except the military and the penitentiary seemed as perilous to human health. Even in London, where the tradition of hospital care was far stronger than in the United States, “the probability of a sick man dying [in] one,” reported a medical board in the mid-nineteenth century, was “many times greater than had he stayed away.”
For wealthy New Yorkers, the alternative was private care: a prominent physician, often under contract, would be summoned whenever a family member or a valued servant took ill. “One visited nice persons in their homes; they did not ordinarily come to one’s office,” wrote a student of the New York medical scene. “It was considered, indeed, a matter of good planning to visit frequently enough to oversee the progress of a case, but not so frequently as to give the impression that one was padding the bill.”
Those who served New York’s best families were a breed apart. Most had graduated from a medical school, studied abroad in Edinburgh or Paris, and apprenticed with a well-known physician—a David Hosack, perhaps—before entering private practice. In the 1830s and 1840s, these men had created a number of groups to promote the latest advances from “the best schools of Europe and America.” At each month’s meeting of the exclusive New York Medical and Surgical Society, papers would be read on topics ranging from smallpox vaccination to a daring breakthrough in pain control: “the inhalation of ether.” But all too often the speakers rehashed an assortment of old bromides—the Miasma Theory, for example, or the finer points of bleeding and purging. One told of curing a case of scarlet fever with “wine whey.” Another explained how he had dislodged a coin from a child’s esophagus. “The treatment,” he said, “was to stand him on his head till it fell out.”
With status, of course, came financial reward. Commanding handsome fees, elite doctors never lacked for clients. One of the legendary tales of this era involved a conversation between John Wakefield Francis, an illustrious New York physician, and a wealthy merchant who had hired him on retainer. “Doctor, I got your bill the other day,” said the merchant, “but I don’t remember any of us being sick this year.” “Very likely not,” Francis retorted, “but I stopped several times at the gate and inquired of the servants how all of you were.”
These were the exceptions, of course. Most New Yorkers saw a lower order of “physician,” with each visit paid in cash and, hopefully, on the spot. “People labor under the delusion that doctor’s fees, especially in New York City, are very extravagant,” a newspaper reported, adding: “This is a mistake.” One medical journal complained that the average doctor earned less in his lifetime than a greedy financier made in “a single day on the exchange.”
The main problem, it appeared, was competition. For those seeking private care, the New York City Directory listed 506 “medical doctors” in 1836, excluding herbalists, homeopaths, phrenologists, faith healers, and patent medicine men. Many of these “doctors” touted a diploma of some sort—and a specialty as well. “Dodge, Jonathan, M.D.,” read a typical advertisement. “Operative Surgeon and Mechanical Dentist, original and only manufacturer and inserter of premium and incorruptible teeth.”
For the poorest New Yorkers, even a Dr. Dodge was beyond reach. Many relied on the home
remedies and patent medicines familiar to all groups, but aimed especially at the “lower classes.” For 25 cents, Dr. Fubarsch’s “Vegetabilische Lebenspillen” offered relief from fever, worms, and hemorrhoids. For 50 cents, Van Pelt’s “Indian Vegetable Salve” promised to make carbuncles and breast lumps disappear. For a dollar, one could purchase “Ladies Silver Pills,” described, rather delicately, as “the rich man’s friend and the poor man’s need.”
There were other options. Virtually all societies distinguish between the “worthy” and “unworthy” poor. In nineteenth-century America, the “worthy” poor were those who innocently lacked the means to care for themselves: widows and children; an injured farmer or tradesman; the blind, disabled, elderly, and insane. The “unworthy,” by contrast, were those who created unseemly obstacles to their own success: drunks and prostitutes; beggars, gamblers, and the chronically unemployed.
Medical care reflected this divide. A prime example was the “Dispensary System,” imported from London in the late 1700s. Similar to the outpatient clinics of today, the dispensary flourished in American cities as a working-class alternative to the almshouse infirmary—the early Bellevue model—that smacked of failure and despair. In 1828, the New York Evening Post praised the Northern Dispensary, which had just opened in Greenwich Village, for providing medical care to “the honest workmen…who [otherwise] must either receive assistance from the charity of neighbors, or be removed to the hospital or perish.”
How did a dispensary separate the worthy poor from the unworthy? A common device was to solicit donations from wealthy patrons, who could then recommend several patients (often a servant or a factory worker). No one would be treated without a “signed certificate” from a patron, and even that was no guarantee. Those deemed unfit or incurable could still be turned away.
Most dispensary cases were routine: a cough, a cut to be closed, a tooth to be pulled. The Northern Dispensary listed a patient in 1836 who complained of a head cold—a neighborhood writer named Edgar Allan Poe. Some stopped in to be vaccinated, especially when smallpox was around; others were drawn by the free potions of the apothecary, often bringing “a bottle or tea-cup to receive and hold the medicine.” Given the rather mundane range of ailments, the mortality rate was low. Reviewing its first year, the Northern Dispensary claimed that 860 patients had been “cured,” 24 had died, and 17 had been “discharged as disorderly.”
The dispensary served a variety of needs. Employers viewed them as good for their workforce, while health officials saw them as buffers against epidemic disease. But no one benefited more from these clinics than recent medical school graduates and physician-apprentices. Dispensary doctors were grossly underpaid, and some feared that the low wages would “lure only the young, unpracticed, and needy members of the profession.” But that was precisely the point. Competition was fierce for these jobs because they offered a path to a more lucrative career. The trustees of the New York Dispensary, the city’s largest, admitted as much when they described their facility as “a practical school for physicians.” By 1860, New York’s five major dispensaries were treating over 100,000 patients each year, making them the main source of clinical instruction for new doctors—and medical care for the “worthy poor.”
Some, however, watched these rising numbers with alarm. Free medical care not only meant fewer paying patients for doctors serving the working classes, it also raised fears about the moral impact of such largesse. The dispensaries “are nothing less than a promiscuous charity,” a local physician complained. “They are the first stepping-stones to pauperism.”
In fact, such complaints had particular targets. For years, dispensary doctors had fretted over their increasingly Irish Catholic clientele. They were so numerous and repulsive, drunk and surly, said one, as to drive away the “deserving American poor.”
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There were times when the combination of poverty, ill health, and circumstance made a hospital stay inevitable. It might be a stranger to the city, a seriously injured worker, a chronic disease sufferer—someone needing more care than a family or dispensary could provide. In 1850, New York City had two major “hospitals.” One was voluntary, the other public. One was privately endowed, the other relied on public funds. One accepted the worthy poor; the other turned no one away.
New York Hospital opened its doors in 1791, “a handsome structure set amid shaded lawns,” a few short blocks, yet a world away, from the almshouse where Bellevue was born. Financed by the city’s leading merchant families, New York Hospital was never meant as a refuge for the down-and-out. Indeed its founding physicians, John Bard and Peter Middleton—the first dissectors—viewed it as the very antithesis of the Bellevue Establishment, which Middleton described as “a public receptacle for poor invalids” and “a reproach to the community.” Such a place, he fumed, was “undeserving of the name Hospital.”
The contrasts were stark. “From the beginning,” wrote the historian of the institution, “New York Hospital had drawn a line between the diseases it would handle and those—mainly chronic and incurable—it would not.” That line was rarely crossed. New York Hospital made this clear in the 1790s when it refused to accept the victims of yellow fever, and again in the 1830s when many cholera cases were turned away. The “do not admit” list also included drunks, vagrants, and those with smallpox, “the itch,” and “contagious distempers.” A compromise of sorts was reached regarding venereal disease: men could be admitted, but women—i.e., prostitutes—could not. The hospital treated mostly short-term patients—those with a good chance of recovering quickly from their ills. “Persons [of] Decrepitude…are considered as fitter Objects for an Almshouse than for this Hospital,” its charter read. In a word, Bellevue.
There were three patient categories at NYH: those receiving free care; those paying a small weekly charge; and merchant seamen supported by the federal government. The largest category—free care—consisted of the worthy poor: those of a “better grade.” Rules abounded. Patients were expected to be “submissive,” to attend Sabbath services, and to read the Bibles placed in every ward. Cursing, gambling, and stealing were grounds for expulsion. Wards were segregated by sex and race, though black patients were rare because attending physicians did not like treating them. No doubt issuing such decrees proved easier than enforcing them, especially where “maniacs” and hard-drinking merchant seamen were concerned. But New York Hospital had the means to resolve these issues—first by constructing a separate insane asylum, known as Bloomingdale, in the northern reaches of Manhattan; then by moving the merchant seamen into their own “Marine House” with iron bars on the windows.
New York Hospital also differed from the Bellevue Establishment in physical design. One had been built as a refuge for the sick, the other a warehouse for the destitute. One had a welcoming facade; the other resembled a walled-in fortress. One had spacious wards with large windows to scatter “unhealthy emanations” and “noxious physical matter.” The other stacked its patients like cordwood. “Imagine a lunatic asylum, hospital, house of correction, smallpox victims and every series of vagrant huddled together [and] crammed with dead and dying,” a report observed. That was Bellevue—circa 1837.
New York Hospital claimed to welcome all types of worthy poor. “Animated by the Principles of Christianity,” its charter declared, “[we] uniformly disclaim any influence of contracted Attachments to any national, civil, or religious Distinctions.” But immigrants often felt uncomfortable there. While the charity wards did see an increase in foreign-born patients in the 1830s, relations could be tense. A Protestant minister at New York Hospital described the Irish he met as “hardened infidels” and “despisers of the Bible.” During a severe typhus epidemic in 1851, the hospital agreed to admit its share of cases. But the decision set off a firestorm among the donors, who thought the victims, mostly Irish, belonged at Bellevue. Within days, the offer was rescinded “for the protection of other patients.”
No medical facility in this er
a of limited hygiene was immune to waves of bacterial disease. New York Hospital would be racked by outbreaks of pyaemia (blood poisoning), trachoma (eye inflammations), erysipelas (a severe skin rash), puerperal fever (a deadly infection following childbirth), and surgical gangrene. These maladies, known collectively as “hospitalism,” reflected the dangers inherent in all such institutions. But here, too, New York Hospital enjoyed advantages that a public institution couldn’t match. Better funded, more selective, and less congested, its patient mortality was consistently lower than Bellevue’s, where the annual death rate sometimes topped an alarming 20 percent.
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In the 1840s, a ray of hope appeared. A new almshouse complex opened on Blackwell’s Island in the East River, dramatically thinning the droves of paupers and lunatics at Bellevue. It didn’t do much good. The mass transfers to Blackwell’s Island coincided with a flood of impoverished refugees from Europe, leaving Bellevue more crowded than before. “Our city is particularly burdened with them,” a bitter official wrote of these new arrivals. “The opportunities for relief [here] are too easily obtained and certainly too eagerly sought.”
By 1850, fully one quarter of New York City’s population was on some form of public assistance, and three quarters of the recipients were foreign-born. The vast majority of prison commitments now read, “Nativity, Ireland,” as did admissions to the almshouse. At the new lunatic asylum on Blackwell’s, the figures for 1850 were: Ireland, 199; USA 97; Germany 53; England 29. A few doctors there took a sympathetic approach, jotting notations such as “privation on shipboard” and “arriving in a strange land” alongside the Irish names. Many of the cases were young, single women overcome with loneliness and despair. Most would be released from Blackwell’s Island in a matter of months, though the asylum superintendent saw little hope for their future. The Irish, he explained, owed their “exceptionally bad habits” to a “low order of intelligence” resulting from “imperfectly developed brains.” When “such persons become insane,” he added, “I am inclined to think the prognosis is peculiarly unfavorable.”
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