Conditions at Bellevue Hospital
Conditions at Bellevue Hospital
Source: Anonymous engraving. Harper's Weekly, 1860. (Image also appears in A. S. Lyons and R. J. Petrucelli. Medicine: an Illustrated History. New York: Abrams, 1978.)
About the Artist: Harper's Weekly was launched in 1857 by Fletcher Harper, one of the four brothers who owned Harper & Brothers, the largest book publisher in the United States at that time. It was Fletcher Harper's second successful foray into magazine publishing following Harper's Monthly, which he had created in 1850 and modeled on the London Illustrated News. By 1860 the circulation of Harper's Weekly had reached 200,000.
New York's Bellevue Hospital, while technically not the oldest hospital in the United States, is a lineal descendant of the original infirmary for soldiers and slaves established in New Amsterdam (now the city of New York) by Jacob Varrenvanger, surgeon to the Dutch West India Company, in 1658. Soon after the English took over the colony, the infirmary was moved and merged with a "public almshouse and house of correction" that was constructed at the site of the present New York City Hall. In 1794, after a yellow fever epidemic broke out along the U.S. eastern seaboard, the facility was moved to Chambers Street. However, the new premises proved inadequate to deal with the epidemic, so the institution was moved again to a mansion on a farm—"Belle View"—outside the then city limits, its present location. The grounds and buildings of the combination hospital, almshouse, and penitentiary institution were gradually expanded over the next forty years; the hospital itself was completed in 1826. New York citizens objected to the continuation of the almshouse and jail at the site, and these components were removed from the hospital grounds in 1847. From that time until well into the twentieth century, Bellevue emerged as one of the premier hospitals and medical schools in the United States.
Bellevue conjures many negative images in popular imagination, particularly regarding its highly publicized unsanitary conditions in the nineteenth century—exemplified by the engraving below—and its psychiatric facilities to which many citizens were involuntarily committed. However, the history of Bellevue reflects many innovations in American medicine. These include the first lying-in ward in New York; the first formal course for midwives; the development of modern public health practices; the first hospital-based ambulance service; the first school of nursing, and the first hospital outpatient department. On a less positive note, the institution was also the first hospital in the United States to establish its own cemetery, in which many patients and staff were buried. Currently Bellevue is the largest city hospital in the United States, treating 26,000 inpatients and handling 400,000 outpatient clinic visits annually. It provides physical and mental health emergency services for New York City, and continues as a teaching hospital and School of Medicine under the auspices of New York University.
In the nineteenth century, sanitary conditions and patient treatment at Bellevue stand out as objectionable. The problems at Bellevue were reported and illustrated in the local press, such as Harper's Weekly, as the reproduced illustration shows. However, it was Bellevue's size and location in the emerging metropolis of New York City that made it the target of investigative reporting and advocacy for indigent and psychiatric patients. Doubtless many institutions in smaller cities exhibited conditions as bad as or worse than those at Bellevue, but these cities lacked the journalistic fervor that has existed in New York. The story of Bellevue is a prominent case study in how the American hospital system, under pressure from watchdogs in the press, local humanitarian organizations, and the medical profession, gradually incorporated rules of compassion and accountability in the treatment of patients. Many of these rules are now incorporated into municipal, state, and federal laws that govern patient care in American health care institutions.
CONDITIONS AT BELLEVUE HOSPITAL
See primary source image.
Early in the nineteenth century, staffing levels at Bellevue Hospital were extremely inadequate and the hospital was managed by incompetent political appointees. A handful of doctors had charge of a burgeoning population of hundreds and then thousands of hospitalized patients. Dedicated staff physicians at Bellevue shared the fate of many of its patients: twenty-seven staff physicians died from diseases contracted on the job at the institution between 1825 and 1884, mainly from typhus, cholera, puerperal fever, and yellow fever. The farm on which the institution had been built was neglected and produced little food. Conditions were appalling and hospital supplies were plundered wholesale. The institutional mortality rate averaged 20 percent per year in those years. An 1837 account from a history of Bellevue describes patients abandoned by nurses and servants due to concerns of typhus, lying with open wounds in filthy blankets without sheets and pillows.
Reports of these harsh conditions, such as the account in Harper's Weekly from which this illustration was taken, began to stir the conscience of laypersons and medical professionals in New York and beyond. The first step toward improving conditions was taken in 1847, when the prison inmates and the smallpox patients were transferred to Blackwell's Island. The mentally ill also were removed to Blackwell's Island. The almshouse was not moved until ten years later. Around that time, theeliteamong New York'smedical profession began to take seats on the institution's governing board, ending the hospital's mismanagement by political cronies. Physician education in the form of clinical lectures on medical and surgical topics was initiated in the middle of the nineteenth century, bringing about a remarkable improvement in the quality of care and reducing the death rate to just over 9 percent by 1853.
The American Civil War (1861–1865) dealt a blow to staffing and conditions at Bellevue. Almost all of the younger doctors volunteered for service and six of the remaining physicians died in yet another typhus epidemic. However, in a more positive development, Bellevue surgeon Dr. Edward P. Dalton, who had organized a vast horse-drawn ambulance service for the Army, created a hospital ambulance service based on the efficient and successful service he had set up for the military.
Although Bellevue made great strides in increasing its capacity, modernizing its facilities, upgrading the physician staff, and introducing antisepsis and sanitation, the poor quality of its nursing staff continued to hurt patient outcomes. Bellevue nurses, attendants, and helpers were originally furnished by the penitentiary. Many of them worked for room and board only, and lacked training, education, and competence. In 1872, Louisa Lee Schuyler, responding to persistent reports of squalor and substandard conditions at Bellevue, established a visiting committee of educated and socially connected women. When these women first toured the facility, they found gloom, poor lighting, lingering unsanitary conditions, and abysmal staffing levels. This committee publicized the shortcomings of patient conditions and care at the institution, leading at last to a flow of taxpayer funding and charitable donations that began to markedly improve patient treatment and illness outcomes.
As mentioned above, the mentally ill were transferred from Bellevue to Blackwell's Island in the late 1840s. This raises a question regarding the conditions and treatment of the mentally ill in New York in the middle of the nineteenth century. Did New Yorkers remove a problem from Bellevue Hospital only to relocate the same problem to a more remote and less visible part of the city? An anonymous account of the "Lunatic Asylum" on Blackwell's Island that appeared in Harper's New Monthly Magazine in 1866 seems to put that concern to rest. The following excerpt provides insight into local attitudes toward the insane as well as into the conditions that were maintained for them at that time.
In the construction of ordinary asylums attention is given more to the homelike comforts than to the great strength of the establishment. It is the moral power that holds the patients more effectually than strong rooms, and probably there is no asylum in the country, except that at Auburn, from which a sane man could not readily escape. In the Asylum on Blackwell's Island there are no rooms really stronger than the usual sleeping-rooms of the hotels in the city, and the only appearance of extra strength is in the cast-iron sashes of the windows, which might be readily broken. They are well adapted, however, to common cases of insanity, but are insecure for the criminal insane with dangerous propensities … One of the unhappiest results of the reception of this class is, that the other insane feel truly degraded by the association, and are fearful that their own lives are endangered. Many of the patients are exceedingly sensitive, and feel deeply any real or fancied injury or injustice. It becomes with them a matter of complaint that murderers even occupy the same halls with them and sit at the same table. Expressions of feeling arouse a spirit of ill-will and antagonism, and serious quarrels and difficulties result. (Anonymous. Harper's New Monthly Magazine, vol. 32, no. 249, February 1866.)
This passage reveals much sympathy and compassion for the "lunatics" at Blackwell's Island. The article, while thorough in pointing out the shortcomings of care in the institution, expresses a benign attitude toward the care of the mentally ill. It also points out the lack of sensitivity for the patients' concerns shown by the institutional staff. The article further notes that the insane were housed on a separate part of the island from the prisoners. The asylum was located near an area of considerable natural beauty and by a neighborhood of mansions built by wealthy New Yorkers. Thus, while the treatment of psychiatric patients in the early nineteenth century at Bellevue reflected the devastating neglect that all of the patients and inmates suffered there, it appears that transferring the insane to Blackwell's Island was motivated by a desire to improve conditions, not only at Bellevue itself, but also for the mentally ill. By the mid-nineteenth century, therefore, public attitudes toward the mentally ill had already begun to be transformed from punitive to treatment-oriented. Today the overwhelming majority of the mentally ill at Bellevue are treated on an outpatient or emergency basis. The 1994 book Crazy All the Time: On the Psych Ward of Bellevue Hospital provides a vivid contemporary description of these services from the perspective of a Bellevue staff psychologist.
A review of the history of Bellevue supports a largely optimistic assessment of the progress of institutional medical practice in the United States, despite flawed political systems and negligent or malicious officials and employees. Accounts of the hospital's vicissitudes and struggles are gripping and raw. However, the Bellevue of today represents a triumph of the health care professions and the New York community over the extreme adversity of financial neglect and waves of epidemics. Perhaps, the greatest adversity that was conquered, however, was the devastating ignorance on the part of the general public concerning conditions at Bellevue, an ignorance that the vigilance of journalists and the social conscience of citizens finally banished.
Covan, Frederick L., and Carol Kahn. Crazy All the Time: Life, Lessons, and Insanity on the Psych Ward of Bellevue Hospital. New York: Simon & Schuster, 1994.
Bellevue Hospital Center. 〈http://www.nyc.gov/html/hhc/html/facilities/bellevue.shtml〉 (accessed November 20, 2005).
History Magazine. "Bellevue Hospital." 〈http://history-magazine.com/bellevue.html〉 (accessed November 20, 2005).
NYC 10044. "Blackwell's Island Lunatic Asylum." 〈http://nyc10044.com/timeln/asylum/lunatic.html〉 (accessed November 20, 2005).