In a dramatic confrontation, the Visiting Committee demanded that Bellevue close its birthing wards and send the patients somewhere else. “Gentlemen, we have learned the cause of the mortality,” its spokeswoman told the Bellevue Medical Board. “We give you forty-eight hours to remove those women. If they are here at the end of that time, the whole story will be published in the Evening Post.” While no doubt furious at an ultimatum from society-types based on “speculation” from Europe, the board quickly caved in. The maternity wards were closed and the patients moved to Charity Hospital on Blackwell’s Island, along with nurses from the Bellevue Training School.
Progress came slowly. Flare-ups of puerperal fever would continue until 1877, when Hobson and her supporters funded a new birthing facility in an old firehouse near the Bellevue grounds. Run jointly by the Bellevue Obstetrical Service and the Training School, it observed a strict new set of rules. Hands were to be washed thoroughly in a chlorine solution and no staffer was permitted “to be present at autopsies [and then] to assist at surgical operations or the dressing of wounds.” Puerperal fever virtually disappeared.
The victory helped bring professional nursing out of the shadows. In the late 1870s, the Training School had attracted fifty applicants a year. That number would reach 200 in 1880; 1,370 in 1890; and close to 1,800 by the new century. The most striking change, for both critics and supporters at Bellevue, was the sense of order that had spread within the crumbling shells of the buildings, reminiscent of Nightingale in Crimea. “I can still see the wards there,” an intern recalled. “The floor was gleaming, every bed in perfect alignment, the sheets tucked in so tight the patients couldn’t possibly dislodge them.” In terms of basic care, he thought, the nurses “left little to be desired.”
Looking back on the years of struggle to bring professional nursing to Bellevue, Elizabeth Hobson took understandable pride in the progress that had occurred. “The early prejudices, the opposition we had to contend with, have long since vanished,” she wrote in 1916. “Now a surgeon would not undertake an operation of any importance without the attendance of a trained nurse.” A sure sign of this advancement was the expanded nursing curriculum, which added classes in anatomy, physiology, and the basic sciences. Even the once hostile Bellevue Medical Board had come to view the Training School as “an incalculable benefit to [our] hospital.”
But problems remained. Most graduates of the school looked beyond Bellevue and other public hospitals to careers in the private sector, where the pay was better, the hours shorter, the workload less intense. And while the prejudice against nursing per se had surely eased, the public perception of nurses as “all-purpose female service workers,” rather than carefully trained professionals, still lingers. Nightingale’s emphasis on deference and discipline had actually retarded progress, some believed, by endorsing the power gap between doctors and nurses to the point where it became a fixed and natural part of hospital life. “When my mother became a registered nurse [in 1903],” wrote Lewis Thomas, a former NYU Medical School dean, “there was no question in anyone’s mind about what nurses did as professionals. They did what the doctor ordered,” from hanging up his hat and coat to following his precise instructions, though they knew the patients far better than he did. Eighty years later, Thomas could only marvel that so many of his male colleagues still viewed their nurses as glorified “ward administrators and technicians,” despite the immense improvements in nursing education.
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Ignaz Semmelweis never got to see the fruits of his labor. Fired from his hospital position in Vienna, he moved from job to job, a hero to some, an outcast to others. He died in 1865, following his commitment to a mental institution, but the work he pioneered would be studied, and refined, in laboratories across Europe. Known collectively as Germ Theory, it would soon divide America’s medical community as few things had before—nowhere more so than at Bellevue Hospital.
10
GERM THEORY
By 1870, Bellevue was the uncontested giant of American hospitals. With 1,230 beds, its sheer size attracted elite physicians for whom the lure of “interesting” patients outweighed the fear of deadly “miasmas” and physical blight. So great was the clamor for a visiting position that the Medical Board agreed to split the hospital into four divisions—one for each of the city’s major medical schools (Physicians & Surgeons, Bellevue, New York University), and one for “unaffiliated” doctors. Each division would be independent, with the power to appoint senior staff (physicians and surgeons) and house staff (interns and residents): the former chosen by pull and reputation, the latter by pull and examination.
Competition at the low end was especially intense. With America’s medical schools producing thousands of graduates each year, those seeking an internship, the key to a successful practice in the larger cities, often found themselves shut out. An internship required a hospital willing to provide one, and there simply weren’t enough hospitals to meet the demand. Though “merit” supposedly drove the selection process, the criteria could be flexible, to say the least. When applying for an internship at the Massachusetts General Hospital, young William James spoke of the shameless “toadying” that included “courtesy calls” to the homes of trustees. “I have little fears, with my talent for flattery and fawning, of a failure,” James rightly boasted.
City hospital positions were the most coveted and cutthroat. Dr. Hermann Biggs—a future giant in the field of public health—described the Bellevue internship as the “highest honor” a medical school graduate could achieve. Biggs had dutifully enrolled in a “prep course” that tutored applicants for their entrance exam. He hardly seemed to need it—“[You] have passed with the rank of No. 1,” he was told—but dozens of his peers signed up in the hope of gaining an edge. “I am undecided whose course I should take,” a Bellevue applicant wrote home in 1878. “If I take Professor Smith’s class it will cost me fifteen dollars, and if I take Prof. Loomis, it will cost twenty-five. I almost believe it would pay to take Loomis, for…I would at least have his goodwill [and] he is one of the examiners.”
In this case, the extra ten dollars seemed very well spent. “Prof. Loomis’ private class is excellent,” the applicant noted, though that was hardly the reason he signed up. What drove him was the chance to buy favor with the right professor, which, he admitted, “is a trick that is frequently done.” Lacking the talent of a Hermann Biggs, the young man did the next best thing. “I think I can count on Prof. Loomis,” he wrote, and he probably was right. His exam went smoothly, and his internship came through.
Few hospitals could match the young talent that Bellevue attracted. In the late 1870s, its list of interns included two men destined to revolutionize their fields. One was William Welch; the other William Halsted. Both men hoped one day to make Bellevue their permanent home, though neither man did. Their stories, complicated and intertwined, speak volumes about the workings of the hospital in that era and the deep medical divide that eventually drove them away.
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William Welch, the son of a Connecticut country doctor, had been a top student at Yale and P&S before arriving at Bellevue in 1875. “It is certainly the most completely appointed hospital in New York and [perhaps] in the world,” he gushed in a letter home. “We have the best visiting physicians and surgeons in the city; we have the advantages of daily clinics and pathological examinations in the Dead House.” In short, a medical bonanza—cradle to grave.
Welch found a mentor of sorts in Dr. Francis Delafield, a remote presence who ran the morgue and performed the autopsies. One learned from Delafield through silent observation; a wizard with a microscope, he spent long hours stooped over his workbench studying the pathology of disease. Delafield’s case reports on tumors of the lung and the kidney are still considered among the classics of microscopic pathology. The problem, Welch realized, was that he’d gone about as far as he could at Bellevue or any other American hospital; a dead end loomed ahead. In Europe, there were dozens of Delafiel
ds working on subjects barely explored in the United States. Welch saw no choice but to follow his internship with two years of study abroad. “Even assuming that I do not obtain any position in a medical college,” he wrote his father, “the prestige and knowledge which I should acquire…would decidedly increase my chances of success in a large city. The young doctors who are doing well in New York are in a large proportion those who have studied [in Europe].”
William Halsted, the son of a leading New York City merchant, had graduated from Yale two years after Welch, their paths rarely crossing. Halsted rowed, played baseball, and captained the first eleven-man football team in school history. Bored with his studies—there is no record of his ever borrowing a book from the Yale library—he bought a copy of Gray’s Anatomy after attending a few lectures at the medical school with a friend. Somehow, a light clicked on. Deciding to forgo the family business for a career in medicine, Halsted chose the College of Physicians and Surgeons, where his father, conveniently, was a trustee.
Though every bit a proprietary—or profit-making—institution, P&S had a lineage and reputation that few medical schools could match. And it sat only a few blocks from the Halsted mansion on lower Fifth Avenue, adding convenience as well. The lectures at P&S were dull and redundant, Halsted recalled, but the clinics in medicine and surgery—often held at Bellevue—made the drudgery worthwhile. Like Welch, Halsted performed splendidly, writing the best examination essay in his graduating class. And like Welch, he moved on to Bellevue.
Halsted began his internship just as Welch departed for Europe. “In 1876, the year I [first] walked the wards of Bellevue Hospital, New York,” Halsted recalled, “the dawn of modern surgery had hardly begun.” He was referring to the era between the discovery of anesthesia and the triumph of antiseptic methods—a time when the horrors of postoperative infection still haunted the operating room. Determined to be a surgeon, Halsted worked closely with Bellevue’s best, including Stephen Smith and Frank Hamilton. Halsted admired both men, calling them the finest teachers he had known. Where Smith and Hamilton differed, however, was in their opinion of a British surgeon named Joseph Lister. Smith admired him; Hamilton did not. The stakes for American medicine could hardly have been higher.
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In 1876, the United States celebrated its hundredth birthday with a dazzling display of technology and consumerism known as the Centennial Exhibition. Held in Philadelphia from May through November, it attracted ten million visitors—equal to 20 percent of the country’s population. President Ulysses S. Grant opened the festivities, flanked by fellow Union generals Philip Sheridan, Winfield Scott Hancock, and William Tecumseh Sherman in full military dress. For many Americans, the Exhibition proved a respite from troubled times. To the west of Philadelphia, coal mine owners were locked in a violent struggle with immigrant miners, led by the Molly Maguires. From the Great Plains came word that General George A. Custer and his entire cavalry regiment had been wiped out by Sioux warriors at the Little Big Horn. In the South, vigilante violence against newly freed blacks threatened to unravel a decade’s worth of federal policy known as Reconstruction. On top of this, the nation faced a constitutional crisis in which both major presidential candidates—Republican Rutherford B. Hayes and Democrat Samuel Tilden—claimed victory in the 1876 election, raising concerns about who would govern the Republic.
A more optimistic scene awaited visitors to the Centennial Exhibition. For 50 cents, one could climb through the unassembled right arm and torch of the Statue of Liberty, awaiting its final trip to New York harbor. In Machinery Hall, one could watch Alexander Graham Bell show off his telephone, and then tap away on a Remington “typographic machine,” which switched seamlessly from uppercase to lowercase letters with the stroke of a key. A nearby food court showcased a new condiment known as “ketchup” from the Heinz family of Pittsburgh, and a caramel-flavored soft drink called “root beer” from the Philadelphia pharmacist Charles Elmer Hires. While the Exhibition was an international event with numerous foreign pavilions, there seemed little doubt about who owned the future. “The products of the industry of the United States [have] surpassed our own,” lamented the Times of London. “They revealed the application of more brains than we have at our command.”
There was one notable exception to the claim of American superiority. The 1876 Exhibition also hosted the International Medical Congress, five hundred strong, whose speakers included the English surgeon Joseph Lister. Lister had come to America with a radical idea. He believed that the recent discoveries of Louis Pasteur had forever changed the practice of medicine. Pasteur had shown that putrefaction—the decomposition of organic matter—depended on “minute organisms,” or “germs,” suspended in the air and the water, invisible to the naked eye. These microbes, said Lister, were responsible for the postoperative infections that turned the average operating room into a slaughterhouse. Like Ignaz Semmelweis, Lister blamed the problem of infection not on deadly “hospital air,” but rather on the careless habits of the surgical staff. Unlike Semmelweis, Lister supplied both a theory of causation and strong clinical evidence to make his point.
Pasteur had employed intense heat and intricate filters to prevent bacterial contamination—neither of which could be used during surgery. Lister thought a chemical compound might work, so he experimented with carbolic acid, a common treatment for neutralizing the stench of sewer gases. At the Glasgow Infirmary, he dipped everything in carbolic acid—hands, fingernails, instruments, table surfaces, towels, and dressings—while using an atomizer to spray the air. The infection rate dropped so dramatically that Lister published his findings in The Lancet, England’s leading medical journal. “Comparing the aggregate results,” he wrote, “we have—
Before the antiseptic period (1864–1866), 16 deaths in 35 [amputations]; or 1 death for every 2 ⅕ cases;
During the antiseptic period (1867–1869), 6 deaths in 40 [amputations] or 1 death for every 6 ⅔ cases.”
Antiseptic surgery had dramatically reduced the risk of blood poisoning and hospital gangrene, Lister noted. “Its effects upon the wards lately under my care [in Glasgow] were in the highest degree beneficial, converting them…into models of healthfulness.”
The American response was predictable. Medical theories from Europe had long faced stiff resistance, and the battle over antiseptic surgery would be no different. Lister, forty-nine years old at the time of the Centennial Exhibition, had been invited to speak by Samuel Gross, seventy-one, president of the American Medical Association. Immensely self-assured—his relentlessly immodest autobiography ran to 855 pages—Gross was so revered for his surgical skills that the International Medical Congress, which Gross also headed, had commissioned a mural of him at work by a local artist named Thomas Eakins.
Today The Gross Clinic is considered a masterpiece, one of the finest American paintings of the nineteenth century. The enormous canvas, eight feet high and six and a half feet wide, depicts Dr. Gross pausing in reflection beside an operating table, a bloody scalpel in his right hand, as one of his numerous assistants leans over to probe the partly clothed patient’s open wound. In the foreground lies an open box of menacing surgical instruments; to the left sits a grief-stricken woman, likely the patient’s mother, her arm slung feebly over her eyes; in the background are row upon row of spectators, the clearest of whom (often identified as Eakins himself) is intently scribbling notes.
The mural was supposed to hang in the Centennial Exhibition’s main gallery. But critics were so stunned by its realism, calling it “a picture strong men find difficult to look at,” that a decision was made to move it to an army hospital far from the Exhibition grounds. Some questioned Eakins’s motive. Was the mural intended as a tribute to the medical craftsmanship of Dr. Gross, or was it something more subversive? What is obvious—to modern eyes, at least—is the absence of basic antiseptic methods. Gross and his assistants are wearing business suits. There is no water for washing the instruments and no carbolic acid in sight. T
he patient is wearing the soiled clothing he arrived in, his dirty socks prominently displayed. Blood is everywhere—on scalpels, dressings, and bare hands. Was Eakins making a statement about the willful ignorance of Dr. Gross—a man who scoffed at Pasteur’s theories and needlessly exposed his patients to disease?
Furthermore, why would Gross ask Lister, of all people, to address the International Medical Conference? The most likely answer—aside from an actual interest in the subject matter—is that Gross hoped to debunk Germ Theory and antiseptic surgery on a grand stage. Gross had invited a number of skeptical surgeons, including Bellevue’s Frank Hamilton, to question Lister on his methods. One by one, they rose to challenge the need for antisepsis and to present their own remedies for combating surgical infection, a list that ranged from “cold water” sprinkled on the open wound to “rest—quietude of the limb.”
Then it was Hamilton’s turn. “A large portion of American surgeons seem not to have adopted [Lister’s] practice,” he began, “whether from a lack of confidence or for other reasons, I cannot say.” Hamilton didn’t belittle the Englishman; he simply ignored him—much as he ignored Germ Theory as a silly notion that would mercifully disappear. For his part, Hamilton endorsed something called the “open air treatment” in which “no dressings whatever are employed,” leaving the wound free to excrete pus until it healed on its own. “At Bellevue Hospital,” he said, citing no real evidence, “this method has been employed recently, in quite a number of major amputations, with remarkable success.”
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