Bellevue

by David Oshinsky

  —

  There never was a time when Bellevue appeared even remotely trouble-free. Its list of challenges in the new century—half-completed buildings, fickle city budgets, surging immigrant numbers, conflicting medical school agendas, the private patient revolution—seemed no larger, or bleaker, than before. Bellevue was Bellevue, a municipal eyesore most New Yorkers couldn’t imagine living without. Even those who would never think of setting foot inside understood its need to exist. A writer for the New York Times captured Bellevue’s essence in Dickensian prose: “It gathers the dead and dying from the rivers and streets and is kept busy night and day with the misery of the living.”

  In the late summer of 1918, as World War I turned in America’s favor, a pandemic of biblical proportions swept the globe. Some scholars have traced its origins to Spain; others to an American army camp in Kansas; still others to the battlefield trenches in France. Before it ended, the so-called Great Influenza would kill more people, in a shorter time, than any other outbreak in history, with fifty to eighty million lives lost worldwide. One American in four would contract it before the pandemic subsided, and close to 700,000 would die. No statistic can properly convey this horrific damage, but one comes close: in 1918, the life expectancy of the average American dropped by twelve full years.

  Previous influenza epidemics had taken their greatest toll among those with fragile immune systems, especially the very young and very old. This flu was different; the highest death rates would occur among adults in their twenties and early thirties. Numerous theories have appeared to explain this anomaly, the favorite being the “cytokine storm” in which a vigorous immune system responds so forcefully to the invading microbes as to literally drown the lungs in gooey phlegm, dead cells, and assorted debris. William Welch was stunned by the carnage he saw in the quarantine wards at Fort Devens, Massachusetts, in 1918. “This must be some new kind of infection. Or plague,” he told a young army physician, who never forgot the look of panic that crossed the great man’s face.

  Bellevue received its first influenza cases in mid-August—three sailors from the Brooklyn Navy Yard, all dead within the week. “High temperature, short of breath, and bluish,” noted the resident in charge. By September, the disease had felled hundreds, then thousands, of New Yorkers. As it spread, the Health Department banned spitting in public as well as “promiscuous coughing and sneezing.” To prevent crowding on the subways, stores and factories staggered their working hours, and theaters cut their ticket sales in half. The public schools remained open, but only because the health commissioner thought the classrooms to be safer for children than the slums where so many of them lived. Before long, public libraries had stopped lending books, gauze face masks had become regular attire, and people had stopped shaking hands.

  In October, Bellevue saw more admissions than it had at any time in its history. Resident Connie Guion was soon treating five hundred victims by herself. There was little to be done for them beyond some aspirin and whiskey to dull the pain. “It got to the place where I would only see the patients twice—once when they came in and again when I signed their death certificate,” she recalled. With so many bodies in the morgue, the city hired extra gravediggers to handle the overflow.

  Guion’s most vivid memory was of a teenage Italian boy who had lost ten members of his family to the epidemic. The father, now dead, had run a neighborhood cigar store. The boy asked her, “Doc, what do you think I should do? Should I use up all my money burying [them] or do you think I should let them go to Potter’s Field?” Guion told him to save the cigar store and let the city assume the burial costs. The store survived—a small sign, she thought, of the enduring human spirit.

  Patients weren’t the only casualties. So many nurses and doctors took sick that city officials wondered whether to limit new admissions to public hospitals until the crisis eased—a suspension of Bellevue’s most sacred rule. They decided against it; no one would be turned away, though some patients wound up sharing a bed or sleeping on the floor.

  The city’s voluntary hospitals played a lesser role. Their policy was to accept as many influenza patients as their charity wards could normally hold. When a bed opened, a new admission would occur. There would be no doubling up, no cots in the hallways, and no invasion of the rooms set aside for private patients.

  Meanwhile, work proceeded on a flu vaccine, led by Hermann Biggs and his disciple, William Hallock Park. Both men had trained at Bellevue, and both held appointments at NYU Medical School, where the field of virology was rapidly taking hold.

  To develop an effective vaccine, one must isolate the responsible pathogen—an impossible task in 1918 given the mysteries of the endlessly mutating influenza virus. Park did his best in an atmosphere of growing alarm as his own staffers fell, one by one, to the disease. Believing, correctly, that the high death rate had less to do with the initial bout of influenza than with the bacterial pneumonia that followed, Park injected one group of volunteers with weakened strains of pneumococcus to produce an antibody reaction, while simply observing the other group. The results were discouraging. Those who received the vaccine had twice as many lung infections as those who didn’t.

  Park was beaten. “Our final conclusion,” he admitted, “is…that the micro-organism causing this epidemic has not yet been identified.” A decade later, in 1929, the biographer of Hermann Biggs described the vaccine debacle as “a chastening experience for [those] who had come to feel that modern science had placed in their hands weapons of almost unlimited power for defense against epidemic disease.”

  The Great Influenza disappeared as suddenly as it had come. Bellevue had been staggered, at times overwhelmed by the crisis, but its credo remained intact. When it came to treating the sick, whatever the circumstances, there was always room for one more.

  * * *

  * In 1898, the separate NYU and Bellevue Medical Colleges merged into a single institution known as the University and Bellevue Hospital Medical College. The stated reason was a fire on the Bellevue grounds that damaged parts of the Bellevue Medical College building, though both institutions had been struggling financially for years. The merger allowed the colleges to pool their resources and to trim overlapping faculty. The acrimony it produced—who would stay and who would leave—was substantial. Indeed, a number of departing faculty members negotiated with Cornell University, which then offered a two-year “preparatory curriculum” in medicine in Ithaca, New York, to create a four-year medical college in New York City, which opened in 1898 with substantial funding from Cornell alumni. Given its solid financial standing and Ivy League credentials, Cornell Medical College had no trouble getting off the ground. In short order, its faculty and students were fully integrated into Bellevue Hospital for clinical instruction. In 1935, Bellevue/NYU formally changed its name to NYU Medical College.

  14

  CAUSE OF DEATH

  The 1920 U.S. Census revealed a country barely imagined a generation before. The population now exceeded 100 million, more than double the figure in 1880, and larger than that of any European nation except the infant Soviet Union. Even more telling were the demographic changes: America, the land of farms and open frontiers, had officially become “urban.” More people were living in cities than in rural communities—a shift accelerated by mass immigration from Europe and the exodus of Southern blacks to the industrial North and Midwest. Manufacturing jobs were there for the taking—in steel and automobiles, in meatpacking and the garment trades. World War I had made the United States a creditor nation, its banks, factories, and troops having turned an unspeakably brutal conflict in favor of the Allies. With Europe exhausted and reeling, American finance and industry dominated the world stage.

  New York City stood at the center of it all. Its population of 5,650,000 was twice as large as second-place Chicago. Wall Street was the undisputed king of capital transactions, and midtown Manhattan, a few miles to the north, headquartered 75 percent of the nation’s four hundred largest corporatio
ns. The Woolworth Building, the Metropolitan Life Insurance Tower, the Bank of Manhattan, the soon-to-be Chrysler and Empire State Buildings—all symbolized the city’s economic clout. “The American does not realize what a shock New York can be to a European who has never before seen a building higher than ten floors,” a British writer marveled. “The effect is bewildering.”

  It wasn’t simply the skyscrapers. The shock value of New York City came in many forms. The splashy wealth, jam-packed streets, and immigrant enclaves spoke to one part of it; the cultural tone to another. “The parties were bigger…the morals were looser and the liquor was cheaper,” F. Scott Fitzgerald wrote of Roaring Twenties New York in The Great Gatsby. Though his vision hardly compared to that of mere mortals, few would deny the excess, escapism, and lawlessness that permeated city life. Many blamed it on rural attempts to counter urban “immorality” through repressive measures like Prohibition, the constitutional amendment that banned the manufacture, sale, and transportation of alcoholic beverages starting on New Year’s Day 1920. Opinion polls showed most Americans coming to loathe and openly flout its provisions, nowhere more than in New York City, where thirty thousand speakeasies cropped up to dispense illegal alcohol, much of it foul-tasting, some of it deadly. Over time, Prohibition would be blamed for the birth of organized crime, thousands of fatal poisonings, and the resurgence of Tammany Hall led by “wet” politicians like James J. “Jimmy” Walker, the aptly named “nightclub mayor.” Jazz Age New York had become America’s “city on a still.”

  Prohibition changed Bellevue as well. The flow of illegal whiskey not only taxed the hospital’s emergency rooms, it also fueled a curious new specialty, developed in Bellevue’s pathology labs, to provide a scientific explanation for the manner in which a person died. Its founders called it forensic medicine.

  —

  Every so often, following a sensational exposé of municipal corruption, the New York state legislature would rise up and pass a well-meaning bill in response. One such moment arrived in 1915 when Leonard Wallstein, New York City’s fastidious, anti-Tammany commissioner of accounts, published his investigation of the local coroner’s office. In scathing terms, Wallstein described it as a sinkhole of “favoritism, extortion, and malfeasance,” adding that crimes of “infanticide and skillful poisoning” routinely went unpunished because the prosecutor’s office received “no adequate medical data whatever.”

  The main problem, Wallstein noted, was the political nature of the beast. Coroners were elected officials, meaning that most were “absurdly ignorant” of medical matters but remarkably well versed in the petty graft of Tammany Hall. According to Wallstein, the list of coroners since 1898, the year of New York City’s consolidation, included “eight undertakers, seven politicians, six real estate dealers, two saloonkeepers, two plumbers, a lawyer, a printer, an auctioneer, a wood carver, a carpenter, a painter, a butcher, a marble cutter, a milkman, an insurance agent, a labor leader, and a musician.” Occasionally, an actual doctor would be elected—a dependable hack plucked from the ranks of “medical mediocrity.”

  With the report in hand, the state legislature abolished the old system. There would be no more elections for coroner in New York City. All future hiring would be done by a “chief medical examiner” selected from a pool of “skilled pathologists [holding] the degree of M.D. from an approved institution of recognized standing.” Mayor John F. Hylan wasn’t thrilled by the change. “We have had all the reform that we want in this city for some time to come,” he fumed. Hylan tried to subvert the process but the Republican governor intervened. The new post went to Dr. Charles Norris, the director of laboratories at Bellevue Hospital and a professor of pathology at NYU Medical School.

  Standing well over six feet, the hard-drinking, goatee-sporting Norris came from money and privilege, his ancestors having founded Norristown, Pennsylvania. A graduate of Yale and the College of Physicians and Surgeons, Norris had traveled to Europe for further study in pathology and bacteriology—treading the same path as William Welch, whose laboratory research he deeply admired. Arriving at Bellevue in 1904, as plans for a new pathology building were under way, Norris took an early interest in forensic medicine. Among the improvements he helped oversee was the expansion of the city morgue, making it the largest such facility in the world. When his job offer arrived in 1918, Norris had been teaching and researching at the hospital for more than a decade. He demanded, quite logically, that the Office of Chief Medical Examiner be headquartered where “the greatest activity resided,” and that meant Bellevue. It took some hard lobbying, but Norris got his way.

  By law, the new Medical Examiner’s Office was responsible for investigating all cases in which a victim died “from criminal violence, or suicide, or suddenly when in apparent good health, or in any suspicious or unusual manner.” Given that more than 25 percent of New York City’s fatalities fell into one of these categories, the workload was daunting. Was the body in the river a simple drowning or something more sinister? Was the gunshot wound the work of a murderer or perhaps self-inflicted? Had the victim died of natural causes or had she been poisoned?

  By all accounts, Norris welcomed the challenge. His fiefdom covered several floors of the Bellevue pathology building, from the basement morgue to the laboratories and animal quarters housed directly above. “It would be imprecise to say that Dr. Charles Norris loved the job of chief medical examiner,” a writer noted. “He lived it and breathed it….He gave it power and prominence and wore himself into exhaustion and illness over it.” His faculty position at NYU provided another advantage. Norris couldn’t fire all the holdovers from the previous system; that was politically impossible. But he could bring in fresh blood to run the new laboratories he created—the most important addition being a young NYU chemist named Alexander O. Gettler.

  It proved a spectacularly good hire. Born in Austria to Jewish parents who emigrated to Manhattan’s Lower East Side, Gettler had attended public schools before entering the City College of New York, which accepted students based on grades and a competitive exam, and, best of all, was free. Spending his nights as a ticket-taker on a ferryboat, Gettler got a doctorate in chemistry from Columbia, where his reputation for creativity earned him an instructorship at NYU Medical School, which welcomed Jews, and a laboratory slot at Bellevue. It hardly mattered to Norris that the young man lacked a medical degree. No one knew more about the adverse effects of toxins on the human body—or how they got there—than the brilliant, irascible Alexander Gettler.

  Superficially, at least, the two men were polar opposites: Norris the physically imposing, Yale-educated, old-stock American living luxuriously on Manhattan’s Upper West Side; Gettler the diminutive product of immigrant neighborhoods and public education living modestly in the outer reaches of Brooklyn. What bound them together was an abiding faith in laboratory research. Forensic medicine had yet to emerge as a legitimate pursuit in the United States. The very idea of a medical examiner’s office in an American city—much less one propelled by serious science—was striking in itself.

  Skepticism abounded. For most of the 1920s, the Medical Examiner’s Office would get far less funding than the old coroner’s system had received. Money was so tight early on that Norris used his entire $6,000 annual salary, and sometimes his personal fortune, to meet the department’s basic needs. “All new equipment purchased in 1921 had been paid for by Norris himself or by his staff; every test tube, every scalpel, a new scale to weigh tissue samples, a small brass microscope to study tissue damage. All of it.”

  The results were nothing short of remarkable. Starting from scratch, Norris and Gettler devised ways to examine semen stains on clothing, trace the trajectory of a bullet, detect minute levels of different poisons in the system, and then determine the body’s exact tolerance for each one of them—the so-called lethal dose. In the 1920s and 1930s, these two men didn’t simply revolutionize the field of forensic science, they were the field.

  Riding the freight elevator bet
ween the basement morgue and his fourth-floor laboratory, Gettler would return with vials of blood, tissue samples, and body parts to examine. When working on a particularly difficult case—a rare or unfamiliar toxin—he’d visit his local butcher, buy a few pounds of raw meat, “spike it with the substance involved, and then determine how efficiently he could recover the substance and how conclusively he could identify it.”

  Gettler’s experiments relied heavily on animals, especially dogs. One high-profile case involved a woman who had bled to death in her doctor’s office from a bungled abortion. Her autopsy showed suspiciously high levels of chloroform in her brain, leading prosecutors to charge her doctor with performing the (then illegal) procedure himself, which he vigorously denied. The abortion had occurred elsewhere, he swore, adding that the woman had come to see him shortly afterward, and that he’d done everything possible to save her life.

  Gettler had his doubts. After completing the woman’s autopsy, he injected ten dogs with varying amounts of chloroform to observe their behavior. Then he sacrificed them to measure the level of chloroform in their brains. His conclusion was unambiguous: the victim couldn’t possibly have walked into the doctor’s office under her own power. The chloroforming—and thus the operation itself—must have been done there. A jury agreed, and the doctor went to jail.

  Gettler also used dogs to test his theories regarding drowning and intoxication. Determining whether a body that washed ashore had fallen drunkenly from a pier or been dumped into the water already dead was always guesswork for the coroner, who generally took the word of the police. Gettler wanted more evidence. Knowing that water in the lungs enters the heart’s left chamber before circulating through the body to reach the right chamber, he correctly assumed that one could differentiate between a suicide or an accident, where the victim was still alive in the water, and a homicide, where the victim was already dead, by comparing the contents (especially the salt level) in the two chambers. A major difference would imply the former, because the victim had survived long enough to pump the blood from one chamber to the other; no difference would likely mean murder. Gettler drowned a fair number of dogs before declaring his research a success.