Bellevue

by David Oshinsky

  Through constant practice, Cournand and Richards became masters of cardiac catheterization—developing better needles, stronger nylon tubing, and safer ways to enter the heart without nicking a wall or causing dangerous arrhythmias. In 1947, Richards sent a memo to the Columbia administration citing the progress the two men had made. Cournand, he wrote, had perfected “the technique for which he is now known throughout the world of medical science—namely the successful passage of a catheter along the vein into the chambers of the heart.” The procedure had opened a vital window into the causes of cardiopulmonary disease by allowing researchers to precisely measure the volume of blood pumped from the heart to the lungs. Stroke, shock, hypertension, congestive heart failure—all could be carefully studied now, leading to breakthroughs in cardiac care and the development of lifesaving drugs.

  Nine years later, the Nobel Committee used similar language to honor the work of Cournand and Richards. And it awarded a share of the prize, somewhat controversially, to the little-known German researcher who had invented the procedure before joining the Nazi Third Reich as a physician and a propagandist: Werner Forssmann.

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  By war’s end, Bellevue had become a magnet for cardiopulmonary research. “One rubbed neurons with the best and the brightest on a daily basis,” a former student recalled. “Eminent physiologists from all over the world visited each time they came to the country for a meeting or a vacation.” The laboratory hired staffers from Europe, Asia, Latin America, and Australia—a rarity in those days—and took pride in judging them on merit alone. “I don’t know if it has anything to do with my being a Frenchman,” Cournand once boasted, “but at Bellevue, from a very early time onward, I was always in favor of using the best talent I could find regardless of race, religion, or sex.”

  That talent did, indeed, include a large number of women and Jews. And Cournand, a man of no small modesty, claimed to have hired Bellevue’s first African American secretary as well. While discrimination in medicine was still a serious problem—the profession being overwhelmingly white, Protestant, and male—the hospital had been a liberalizing force for change. Part of it was Bellevue’s standing as the flagship of a largely immigrant city, and part of it was Bellevue’s close relationship with NYU Medical School, which didn’t have a quota system for Jews and was known for favoring a “female presence” in certain services, including Chest and Psychiatry, where many of the patients were adolescents and children. “Women always fared better at Bellevue,” a pediatrician noted, “and this was very well known.”

  Though close to half the patients in Bellevue’s sprawling Chest Service were children, it didn’t have a formal pediatric unit until the 1920s, when Dr. Edith Lincoln took on the job. A graduate of Vassar and Johns Hopkins Medical School, Lincoln had arrived in 1918 as one of Bellevue’s first women interns. It hadn’t been easy. Assigned to take her meals with the nursing staff, Lincoln had demanded a seat at the intern’s table, and won. (In retribution, she was warned for wearing her skirts too high.) There was no denying the quality of Lincoln’s work, however, or the extremely long hours she put in. One of the reasons for hiring her, a male colleague admitted, was that she didn’t have to worry about seeing private patients because her husband, a prominent New York physician, “earned enough…for Edith to devote herself completely to her work in tuberculosis.”

  By the 1930s, a tuberculin skin-patch test had been devised and X-rays could reveal the extent of damage to the lungs. But with no cure in sight, Lincoln could do little more than adopt a holistic approach to the disease, prescribing a good diet, rest, sanitation, and fresh air. Those who visited her wards were struck by the attention to the children’s social needs as well—the donated books and toys, the musical instruments, typewriters, and sewing machines. Sulfa drugs raised hopes in the 1930s, but the promise quickly faded. Lincoln’s pediatric unit recorded an annual mortality rate approaching 25 percent, and those who worked in the building were at heavy risk themselves. “Well, actually I had a little lesion when I left Bellevue, but it didn’t amount to anything,” an intern recalled of his all-too-common experience. Among the less fortunate was Walker Percy, the distinguished Southern writer, who abandoned medicine after contracting a near-fatal case of tuberculosis while doing autopsies in the Bellevue morgue.

  Then, in the 1940s, came word of a miracle. Biologists at Rutgers University revealed that a soil-based derivative had shown great potential in killing the tubercle bacillus. The laboratory’s director, Selman Waksman, called it streptomycin, and the early trials, including those at Bellevue, were quite astonishing. Edith Lincoln’s unit saw its mortality rate plummet to 5 percent. In 1952, Waksman would be awarded the Nobel Prize for discovering “the first effective antibiotic against tuberculosis.”

  At Bellevue, meanwhile, Dr. Lincoln was busy collecting data for one of the largest medical studies of that era—tracking close to three thousand TB “survivors” from the time they entered her unit until their twenty-fifth birthday. Popular culture at the time still tended to romanticize tuberculosis as the disease of tormented geniuses—Chopin, Chekhov, Kafka, Stravinsky, Stephen Crane, the Brontë sisters—or showed victims lounging at a plush retreat in the Alps or Adirondacks. But Lincoln’s study reinforced what health officials and social reformers had known for decades: tuberculosis was a disease of the slums. The patients, almost without exception, “came from low socioeconomic backgrounds…poor, crowded homes [containing] tubercular adults.” Nearly half these children were black and Puerto Rican at a time when their combined percentage in Manhattan, while climbing rapidly, was still below 20 percent.

  Unlike Cournand and Richards, who had no trouble attracting the limited government funds then available for medical research, Lincoln relied on smaller grants from private sources like the popular Christmas Seals direct-mail campaign:

  Put this stamp with message bright

  on every Christmas letter;

  Help the tuberculosis fight

  and make this New Year better.

  Her study proved a gold mine for policymakers, showing, for example, that age was a key factor in determining mortality: infants and the very young were at greatest risk, she concluded, recommending that medical resources be directed their way. But Lincoln’s most vital data related to antibiotic use. They showed that patients given streptomycin in combination with certain other drugs did even better than those taking streptomycin alone. At Bellevue, the addition of the antibiotic isoniazid lowered TB mortality in the children’s unit to 1.5 percent—a success rate confirmed in later trials by the U.S. Public Health Service.

  Like Lauretta Bender, who became a role model for women entering child psychiatry at Bellevue, Edith Lincoln did much the same for women entering pulmonology and public health. “Word soon spread that [Lincoln’s superiors] did not believe that women were necessarily an obstacle, and competent females began to flock to the service,” a disciple of Lincoln’s recalled. Some worked alongside Cournand, others were drawn to clinical work in the wards, especially pediatric TB.

  Lincoln never got the acclaim of other researchers at Bellevue, though her studies of multidrug therapies would help reorient the treatment for tuberculosis—and later, some believed, for HIV/AIDS. Seeing herself primarily as a clinician, she took pleasure in watching her once jam-packed TB wards shrink to the point where the empty beds outnumbered the occupied ones, and inpatient admissions gave way to the outpatient service. For Edith Lincoln, that legacy seemed more than enough.

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  In 1947, Dickinson Richards was named director of Columbia’s First Division. Judging from his correspondence, he ran it the same way he’d run his laboratory—warmly encouraging creativity and skewering those who didn’t measure up. “I feel obliged to complain to you about the performance of Dr. Hutchinson,” read a typical blast to one of his department chairs. “It is perhaps not necessary to give you every single instance upon which this complaint is based, since in point of fact he has not made a singl
e presentation which has been satisfactory.”

  His most scathing criticism, however, was directed at the city. Bellevue—America’s premier public hospital—seemed in serious decline, a victim of decades of municipal neglect. Its laboratories, once among the nation’s finest, were now too cramped and antiquated to meet the sophisticated demands of medical science. “Our most serious limitation at the moment is that of space,” Richards wrote his superiors. “[Our] rooms are small and not particularly well suited to the rather complicated research set-up….Furthermore, there is practically no office space for Dr. Cournand, his desk being surrounded by filing cabinets, drawing boards, apparatus, etc., so that he has no privacy and is almost incessantly being interrupted.”

  That he and others lacked adequate lab space for cutting-edge research was discouraging enough; that more than a hundred adult TB patients were constantly stacked in the corridors awaiting a bed was, in his view, a moral outrage. When twenty-eight of the thirty-two Chest Service floor nurses threatened to quit, citing the high tuberculosis rate among the staff, Richards showed his solidarity by vowing to step down as division director and return to his lab. “We all wore masks, but they didn’t do much good,” a doctor recalled. “Working there was risky, with so many patients in such close quarters. Dr. Richards had a saying. He’d tell us: ‘You don’t get TB from those you know have it, you get TB from those you don’t know have it.’ ”

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  Richards would threaten to quit with some frequency over the years, forcing Columbia to lobby for improvements on his behalf. “Dear Dick, I will tell you that…we have no intention of considering your resignation,” his weary medical school dean wrote him following a periodic blowup. “Everyone is more than pleased with the way matters are developing at Bellevue Hospital and I know the city authorities are just as enthusiastic as we are. You are doing a wonderful job.”

  The news of the Nobel Prize in 1956 was a tremendous coup for Bellevue. Politicians lined up to praise the lifesaving research being done at a public institution serving the poor. But when the city rewarded the Cournand-Richards lab with a $30,000 gift, the response wasn’t exactly what the mayor’s office had in mind. Citing the “abysmal conditions” in the TB wards, Richards made his feelings abundantly clear. “I can win the Nobel Prize in Medicine,” he told the press, “but I can’t take care of my patients at Bellevue.”

  When Richards widened his scope to include the entire hospital, city officials angrily returned fire, calling his charges “exaggerated” and “largely untrue.” But this back-and-forth only encouraged others at Bellevue to join the fight. A group representing the hospital’s 450 interns and residents claimed that conditions were even worse than Richards had described. “A man can’t even die in dignity in Bellevue,” one physician lamented.

  Feeling the heat, Mayor Robert F. Wagner, Jr., told reporters that he might “just walk in and take a look”—not “to make a circus of it,” he said, but to judge the situation for himself. That Wagner had barely set foot in the hospital, despite two years in the mayor’s chair and three years before that as Manhattan borough president, seemed a perfect example of what Richards had been saying: those with the power to improve things didn’t seem to care.

  Had Wagner taken that walk, he’d have seen a city within a city spread across eighty-four wards in fifteen buildings covering five full blocks—most built in the heady days of McKim, Mead & White, and barely touched since. On a typical day in the 1950s, Bellevue’s population exceeded ten thousand, including staff, patients, and visitors. Its psychiatric building contained more beds (630) than all but four other hospitals in New York, and its Chest Service (382) ranked in the top ten. Designed when land along the East River was still inexpensive, Bellevue’s horizontal layout contained seventy-five exits and fifty-five elevators, some so old that replacement parts were no longer being made. (A famous hand-lettered sign in the lobby read: “Ring Up For Down.”) Travel among the buildings meant navigating a maze of dingy corridors and stairwells or, for the strong at heart, a labyrinth of rat-infested underground tunnels stretching the length of the hospital grounds. Stray cats roamed the basement where the doctor’s dining room was located, easing the rodent invasion. Those who stopped in for leftovers—what the dead-tired house staff called “the midnight meal”—had a slogan for the spread: “chicken/rule out tuna.”

  Bellevue had no air conditioning. Surgeries were routinely canceled during heat waves because the operating rooms felt like saunas. The electrical system ran on obsolete direct current (DC)—a rarity in large complexes by the 1950s. Forty-bed wards were still the rule, with the sickest patients up front near the nurse’s desk and a single open bathroom in the back. “If a patient needed privacy, say for a physical examination, screens were moved into place around the bed,” an intern recalled. “This was also done when it was decided a patient was about to die.” Cornell and Columbia had begun moving some of their laboratories off-site, and patience was wearing thin. There were rumblings that both might pull up stakes unless physical improvements were made. In a memo to the Bellevue administration, the division heads complained bitterly of the status quo: “It seems to us a sorry reflection upon the city of New York that the largest hospital in Manhattan, with its close affiliation with three of the leading medical schools in the country, should subject patients on the wards to such…miserable conditions of living…as now exist.”

  This was hardly a novel complaint. There’d been calls to tear down Bellevue during the typhus epidemics of the 1840s, the puerperal fever outbreaks of the 1870s, and the Great Influenza of 1918–19. Once again a chorus of staffers, led this time by a Nobel laureate, was portraying the hospital as a menace to those it served. Either fix it or build a new Bellevue, they demanded—one or the other.

  The press quickly joined in. “NOBEL WINNER SEES BELLEVUE IN SORRY STATE,” warned the Herald Tribune. “For the sake of decency and pride, the city should take immediate steps to clean up the Bellevue mess,” declared the World Telegram. Even the pugnacious Daily News took a sympathetic stand. “Bellevue is more than a city hospital; it is the very life beat and death rattle of the city. Bellevue is the city’s people, fighting for their lives.”

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  The Daily News got it right: Bellevue did mirror the “life beat” and “death rattle” of the city. An average of 2,600 babies were delivered at the hospital each year in the early 1950s—an eye-popping 8 percent of the recorded births in Manhattan—while thousands of bodies were autopsied in its morgue. As the region’s premier teaching facility, Bellevue had trained more than 10 percent of the doctors currently practicing in the New York metropolitan area, with many still on staff. Peeling paint and obsolete elevators aside, the hospital remained a vital part of city life. As two journalists reported after a thorough survey in 1957: “the current uproar should not be allowed to obscure the fact that Bellevue, despite its structural failings, is yet capable of providing the finest medical care to be found anywhere.”

  Dr. Salvatore Cutolo, the hospital’s longtime deputy superintendent, saw better days ahead. “Contrary to popular belief,” he wrote in 1956, Bellevue no longer catered to bums, drunks, addicts, felons, and lunatics. Seventy percent of its current patients came from “the city’s respectable poorer classes.” They were “decent individuals from tidy, if humble homes” who didn’t need to be “deloused.”

  Of course, Bellevue administrators had been saying as much for two centuries. And, accurate or not, it seemed to miss the point. The hospital’s future now depended less on the personal qualities of its patient population and more on its size. Following World War II, the number of New Yorkers using Bellevue began to decline. Where the Great Depression of the 1930s had seen an exodus of paying patients from voluntary hospitals into the free public system, the return of prosperity had reversed the flow. Even Bellevue’s massive Chest Service had begun to thin out as new antibiotics took hold. With the exception of the Psychiatric Building and the Emergency Department
, which never lacked for business, the hospital was seeing vacancies across the board. According to Dick Richards, Columbia’s First Division in 1951 was running at barely 85 percent capacity. And it would have been far worse, he privately admitted, were not other city hospitals “referring their medical derelicts down to Bellevue.”

  New York City had built an enormous public system over the years—eighteen in-patient hospitals, seventeen thousand beds, and forty thousand employees. (Chicago, by contrast, had one public hospital, as did Boston and Philadelphia.) Providing this safety net was not just a tradition in New York, it was the law. The City Charter guaranteed it, stating: “The Department of Hospitals shall be primarily responsible for the care and treatment of the indigent sick.” Those who could pay “in whole or part” were expected to do so, but rarely asked. Those who couldn’t were welcomed on equal terms. At Bellevue, receipts from paying patients in a typical year accounted for about 2 percent of the hospital’s operating expenses. Tax revenues picked up the rest.

  The system worked well enough until the 1950s because expenses were low and the tax base was strong. Hospital workers, including nurses, were notoriously underpaid; the house staff—the interns and residents who did most of the day-to-day doctoring—cost next to nothing; and the attending physicians were paid by their medical schools. When Dickinson Richards complained about the dismal conditions at Bellevue, it wasn’t hyperbole. Budgets were routinely underfunded, supplies were scarce, and repairs were slow in coming. Doctors freely admitted to hoarding bandages, tape, and ointment for their hospital rounds. Even with the usual “overhead” added in—padded civil service jobs, supplier kickbacks, employee theft—New York could afford to treat everyone who needed hospital care at a modest cost.