Not all of them had been forged on the battlefield. Indeed, many of Hammond’s views on sanitation had come from Bellevue surgeon Stephen Smith, who had spent most of the Civil War in New York City providing health care to the poor. The two men had become allies in these years, facing similar problems in different domains. Where Hammond had confronted a deeply hostile military brass, Smith had drawn an opponent equally determined to bring him down. Dominating New York City’s political landscape, it went by the name of Tammany Hall.
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It would be hard to imagine a more one-sided fight: the lonely health crusader versus New York City’s ever-expanding political machine. Named for the mythical Delaware chief said to have carved out Niagara Falls, Tammany had evolved from an elite club, whose early members included Vice President Aaron Burr and future president Martin Van Buren, into a massive welfare agency for recent immigrants, especially the Irish. Tammany provided everything from jobs and food to bail money and a proper burial—all without preachy condescension. What Tammany got in return were votes, a process facilitated by its role in helping these newcomers to become citizens. By the 1860s, it controlled most of the elected offices and patronage positions in the city.
The indelible face of Tammany in these years was William Magear Tweed, the grand sachem and unquestioned leader. Elected to the New York State Senate in 1868, and a member of the city’s powerful Board of Supervisors, Tweed pushed projects dear to the poor, such as orphanages and public baths. He lobbied the state legislature to fund parochial schools and he put thousands of immigrants on the city payroll, many doing Tammany’s political spadework, or no work at all. New York City—indeed, America—had never seen anyone quite like the three-hundred-pound Tweed. A legendary brawler with a massive appetite for food and drink, mistresses and jewelry, he embezzled funds estimated in the hundreds of millions, lived in a Fifth Avenue mansion with “mahogany stables trimmed in silver,” and became the third-largest landowner in Manhattan. “Plunder of the city treasury…was no new thing in New York,” wrote James Bryce, Britain’s distinguished historian and public servant in The American Commonwealth, “but it had never before reached such colossal dimensions.” Tweed’s bloated persona, compliments of cartoonist Thomas Nast, would come to symbolize the egregious corruption of urban American politics following the Civil War.
Stephen Smith could hardly have been more different. Born on a farm in upstate New York, the son of a Revolutionary War cavalry officer, he’d come to Bellevue in 1850, attracted by its clinical riches. Typhus was then at its height. Working on the wards, he discovered that many of the victims had listed the same address, a tenement on East 22nd Street not far from Bellevue itself. Smith paid a visit—and his life’s calling began. “The doors and windows were broken; the cellar was partly filled with filthy sewage; every available place…was crowded with immigrants, men, women, and children….The necessity of closing this house…until it was thoroughly cleansed and made decently habitable, was imperative.”
Confident he had found the source of typhus in the tenement’s “foul emissions,” Smith tracked down the landlord—“a wealthy man, living in an aristocratic neighborhood”—who couldn’t have cared less. New York City had no Board of Health to complain to, and no laws to protect tenants from neglect. “In this extremity,” Smith recalled, “I visited the office of the Evening Post and explained the matter to Mr. William Cullen Bryant, then editor of that newspaper.”
A leading poet and journalist, Bryant had big plans for New York City; his legacy would include the development of Central Park and the adjoining Metropolitan Museum of Art, and his newspaper was already sparring with Tammany over matters of fraud and corruption in civic life. Viewing Smith as a potential ally, Bryant agreed to pursue the complaint. A reporter was dispatched to interview the offending landlord, who, fearing a front-page exposé, agreed to make the needed repairs.
The incident became a catalyst for sanitary reform. Using Bellevue as his bully pulpit, Smith warned that New York faced a future of ever-widening epidemics, with thousands dying needlessly from disease. And, like Cullen Bryant, he blamed it on the pork and patronage of Tammany Hall. Real reform, both men believed, would require intervention by political forces beyond New York City.
The Civil War intervened. Social issues gave way to military concerns. At Hammond’s request, Smith wrote a popular manual for Union field surgeons and inspected a number of military hospitals. Still, the tug of public health remained. Smith fumed, sometimes out loud, over the nation’s misplaced priorities, at one point describing Tammany as a deadlier threat to New Yorkers than the Confederate army. “The country is horrified when a thousand victims fall in an ill-fought battle,” he wrote in 1863, “but in this city 10,000 die annually of diseases which city authorities have the power to remove, and no one is shocked.”
Not for long, it turned out. That fall, the cream of New York society—John Jacob Astor, Jr., August Belmont, and Peter Cooper, among them—formed a Citizens’ Association to address these concerns. The timing was hardly accidental. The city had just endured the most violent summer in its history—the Draft Riots—and these men could feel the class antagonisms bubbling up from below.
What, exactly, had caused such a dramatic collapse of the social order that July, and what could be done to prevent another? Stephen Smith suggested that both questions might be answered by looking at the squalid living conditions where the violence had been worst. He recommended a survey of “the sufferings, perils, and sanitary wants” of the city, which the Citizens’ Association agreed to fund. The budget was generous; dozens of young doctors—most with a Bellevue connection—were hired to do the legwork. “As a body,” Smith assured the benefactors, “they represent the best medical talent of the junior portion of the profession of New York. Many occupy high social positions, and all [are] men of refinement, education, and devotion to duty.”
The final report, Sanitary Conditions of the City, ran to 367 pages (with seventeen volumes of accompanying data). Directed by Smith, it is now considered one of the most influential public health documents in American history. The investigators—one per ward—compiled every imaginable statistic: births, deaths, and different diseases; the condition of streets and pavements; the disposal of garbage and house-slops; the location of indoor toilets and outdoor privies. There were maps and diagrams charting virtually every structure in the city: schools, churches, tenements, factories, slaughterhouses, taverns, brothels, stables, and pigpens.
More dramatic, however, were the descriptions. From the Fourth Ward inspector came this: “On a piece of ground 240 feet by 150, there are 20 tenant-houses occupied by 111 families, 5 stables, a large soap and candle factory, and a tan-yard….The filth and stench of this locality are beyond any power of description.”
From the Eighth Ward inspector: “The instances are many in which one or more families…of all ages and both sexes, are congregated in [a] single…apartment. Here they eat, drink, sleep, work, dress and undress without the possibility of…privacy. What is the consequence? The sense of shame—the greatest, surest safeguard of virtue, except the grace of God—is gradually blunted, ruined, and finally destroyed.”
From the Fifteenth Ward inspector: “In a dark and damp cellar, about 18 feet square and 7 feet high, lived a family of seven persons; within the past year two have died of typhus, two of smallpox, and one has been sent to the hospital with erysipelas….This occurred but a short distance from the very heart of the city.”
New York was now among the most densely populated places in the world. Close to half the population lived in foul tenements or subterranean cellars that never saw the sun. As a result, its mortality rate far exceeded that of other American cities like Boston and Philadelphia, and had even passed such notorious European pestholes as London and Liverpool. Manhattan Island—blessed with two great rivers, cleansing sea breezes, and abundant vegetation—had become a frightfully dangerous place.
Worse still were the divisi
ons within the city, where the mortality rate for a slum dweller was five times higher than for someone “of a better class.” There always had been differences, the report noted, but not to this degree. The alarming truth was that New York had become two distinct cities: one prosperous, content, and healthy, the other marred by “filth, overcrowding, excrement, putrid exhalations, and disease.”
Time was running out. The current crisis wasn’t just about public health, the report insisted, but about public order as well. The Draft Riots hadn’t occurred in a social vacuum; they signaled the collective rage of the perpetrators, as even a glance at their neighborhoods made clear. The “closely packed houses where the mobs originated seemed to be literally hives of sickness and vice,” the report went on, quoting a witness at the scene. “[It is] difficult to believe that so much misery, disease, and wretchedness can be huddled together…so near our own abodes.”
Armed with the survey, Smith traveled to Albany to testify before the state legislature. In scathing remarks, covered closely in the press, he blamed Tammany for the crisis and begged the legislators for help. No longer could anyone call New York a safe or healthy city, he argued, and no longer could anyone ignore the reasons why. The streets were filthy because local aldermen controlled the contracts for garbage collection, which rarely took place. Privies overflowed into drinking wells because the money allotted for inspections and repairs wound up in the pockets of Tammany hacks. Tenements resembled death traps because well-connected landlords never made repairs. “To what depth of humiliation must [we] descend,” Smith pleaded, before an outraged citizenry stepped forward to say: Enough!
His testimony was, by all accounts, a withering indictment of politics run amuck. Smith had not only called out Tweed and his henchmen for corruption, he’d also accused them of jeopardizing the health and safety of their own constituents—the immigrant slum dwellers of New York. “Practically, [we] are a city without any sanitary government,” he warned. “The evidence proves that at least half a million of our population are literally submerged in filth….Children growing up in this pestilential atmosphere become vicious and brutal, not from any natural depravity, but because they are mentally incapable of [anything else.]”
Smith had some formidable support. Much of the business elite stood behind him, as did the prestigious New York Academy of Medicine and top Republican newspapers like the Evening Post, the Times, and the Tribune, always anxious to bludgeon Tammany’s Democratic machine. In 1866, following intense maneuvering, the state legislature passed a landmark bill, written almost entirely by Smith, which created a Metropolitan Board of Health for New York City and the surrounding area. The key board members would be state-appointed, leaving Tweed and his followers to fume—with good reason—about the “encroachment upon our right to govern ourselves.” Given the mandate to “preserve life” and “prevent the spread of disease,” the board quickly replaced Tammany’s forty-four part-time health wardens—a position normally handed to graft-hungry saloon owners—with a group of full-time salaried physicians.
The Metropolitan Health Act was the first of its kind in the United States. Many consider it a turning point in the history of American city life. Even Stephen Smith put aside his normal modesty to call the law “the most complete piece of health legislation ever placed on the statute books.” Mortality rates in New York City had climbed so dramatically by 1870 that one child in five would not live to see his first birthday, and 25 percent of those who did reach adulthood would die before the age of thirty. Some perished in the terrifying epidemics that periodically swept the region, but many more now fell to endemic diseases related to overcrowding, poor sanitation, and miserable working conditions—in short, the plagues of modern city life.
Where to begin? Each tenement privy in New York served up to a hundred people, and there were no public bathrooms. Slaughterhouses butchered more than a million animals each year, letting the blood run into open sewers and leaving the entrails to rot in the gutters. Horse manure covered the thoroughfares, attracting swarms of flies. “Swill Milk Dairies” (so named because the cows fed on the swill, or waste products, of local breweries) sold a watery liquid almost guaranteed to sicken children. Public markets were littered with rodents and spoiled food.
As both a city health commissioner and a Bellevue surgeon, Smith saw the damage everywhere. His strategy, he recalled, was to attack some of the worst abuses in order to impress the burdened working classes and thereby neutralize Tammany Hall. It seemed to work. Using its police powers, the Board of Health closed down the vile Washington Market (which sued but lost in court) and enforced the seldom-used ordinances against driving herds of cattle through residential streets—the first step in moving all slaughterhouses, cow barns, tanneries, and glue factories out of residential neighborhoods. The board also placed hydrants throughout the city to provide safe drinking water and spent $3,500 to build a public urinal in teeming lower Manhattan, an addition described as “eminently successful and always thronged during the entire day.”
Before long, Smith was claiming that New York’s streets were cleaner than they’d been in years, which likely was true. But more important was the reversal of the city’s alarming mortality rate, which, in the decades following 1870, began a steady decline. There were many reasons for this, as we shall see, but Smith’s role was crucial. A pioneer in what he called “preventive medicine,” Smith championed causes from improving childhood nutrition to developing accurate health statistics to planting shade trees in slum neighborhoods. Seeking allies, he founded the American Public Health Association, which helped turn a well-meaning social cause into a highly trained profession.
No one would do more to make Bellevue a center for medical innovation than Stephen Smith. His footprints are everywhere. The hospital ambulance, the professionalization of nursing, the use of medical photography—all would come alive, in one way or another, through his personal intervention. Generations of Bellevue interns and medical students would inherit his passion for public health.
A food faddist and something of a mystic, Smith slept with his head facing north to keep the mind sharp, while prescribing red wine for most nervous disorders. The very idea of retirement appalled him; he insisted that humans could easily reach one hundred years with the proper mental attitude and medical care. Asked for the secret of his longevity, Smith, who would live to ninety-nine, was typically brief. “Work and keep out of the easy chair,” he said. Anything else? Well, yes, Smith replied with his usual foresight. “Don’t eat too much meat.”
7
THE BELLEVUE AMBULANCE
Read today, a century and a half later, Sanitary Conditions of the City remains a medical tour de force. Combining a researcher’s thirst for data with a moralist’s sense of outrage, it stressed the primacy of public health in the nation’s emerging urban-industrial order. Having written much of the document, as well as the legislation that followed, Stephen Smith had expected New York to become the model for other cities. And that meant finding dedicated professionals to move the agenda forward—much like the young doctors who had done the vital legwork for his survey. Among the top positions to be filled was that of sanitary superintendent, the one formerly used by Tammany to sprinkle patronage among its troops. Smith had a candidate in mind, a former Bellevue intern named Edward Dalton. It would prove an inspired choice—if not in the way that Smith, or anyone else at the time, could have imagined.
Born in Lowell, Massachusetts, in 1834, the son and grandson of physicians, Dalton graduated from Harvard, and then the College of Physicians and Surgeons, before winning a Bellevue internship, where he worked under the formidable trio of Drs. Smith, Frank Hamilton, and Valentine Mott. Small in stature, with thick spectacles and boyish features, he gave “the appearance of extreme delicacy,” his brother recalled, and suffered constantly from illness and disease. When war came in 1861, however, Dalton did what was expected of him, joining the Union Army as a regimental surgeon.
His first tou
r ended quickly. Attached to a New York unit during General McClellan’s failed assault on Richmond, Dalton fell victim to “the unwholesome exhalations of the Chickahominy swamps”—a likely reference to malaria. But he did return to the war in time for the savage fighting at Antietam, where his talent for medical administration caught the eye of those in command. Put in charge of several field hospitals, Dalton wound up supervising “the removal and care of the sick and wounded” in General Ulysses S. Grant’s Army of the Potomac during the final push toward Appomattox. The numbers were astonishing: Dalton’s largest hospital on the James River, an encampment of 1,200 tents spread over two hundred acres, treated close to seventy thousand soldiers enduring battle wounds, dysentery, pneumonia, and other maladies. Never “in the history of the war,” wrote William Howell Reed in his magisterial account of the Union Medical Corps, had anybody run “the complicated machinery of hospital administration…to such perfection.”
And no part of that machinery needed more oiling than battlefield evacuation. The North had entered the Civil War without an ambulance corps because no one believed the conflict would last long enough to justify the expense. This oversight proved catastrophic. For a time, the job of gathering the wounded fell to the lowest elements of the regiment—cooks, drummer boys, and those deemed unfit for combat—using carts, wheelbarrows, anything that moved. In 1862, Surgeon General Hammond had begged the War Department to act, citing “the frightful state of disorder [in] removing the [fallen] from the field.” Having seen the disaster at Bull Run, where hundreds had died of thirst, shock, and exposure, lying untended for days, Hammond convinced General McClellan to form an ambulance corps. Used first at Antietam, it was in full swing by Gettysburg, where close to a thousand horse-drawn wagons, known as “gut-busters” for their painfully rough ride, were on duty round-the-clock.
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