Edwin M. Knights Jr., M.D., relates the history of the hospital that introduced ambulances and modern nursing to the US.
ALTHOUGH NEW YORK'S Bellevue Hospital makes a convincing claim to being the oldest hospital in the US, it was not the first. Master Jacob Hendrickszen Varrevanger, surgeon to the Dutch West India Company, is credited with establishing a small hospital to serve the 1,000 inhabitants of New Amsterdam in 1658. It still existed in 1680, but subsequent records of the English Common Council deal more with the need for a poorhouse and workhouse.
As the city grew to over 8,000 in 1731, the “vagabonds and idle beggars” could not be ignored by the rest of society, and construction of a “Publick Workhouse and House of Correction” was begun in 1735. The budget for this ambitious project was £80 and 50 gallons of rum. The building was ready for occupancy early in 1736, and an upper floor infirmary measuring about 25 by 23 feet contained six beds. Dr. John Van Beuren was appointed medical officer, at £100 a year, which included supplying all medications. Although it had no name as yet, Bellevue Hospital had been born! The rest of the building was also quite remarkable, as it included areas for hard labor, instruction in sewing, knitting, spinning, weaving and working in leather and iron. There was also an adjacent farm. This “occupational therapy” approach to the social problems of the day made this a correctional institution far ahead of its time.
The records are sparse until the time of the Revolution, but periodic large expenses suggest alterations and additions. In 1776, when the city was occupied by the British, inmates were transferred to Poughkeepsie. It is known that large numbers of destitute persons were admitted after a large fire on 21 September 1776. After the evacuation in 1783, the poor were brought back down the Hudson and several outbuildings had to be added to increase the capacity. Poor-taxes to support the alms house became a major burden at this time.
A Belle Vue at the Edge of Cesspools
New York rapidly surpassed Philadelphia in size and importance, and the 1810 census listed a population of 96,373. Sanitation was almost non-existent; disease was rampant. Severe epidemics of yellow fever ravaged the city annually from 1794 to 1805; waterfront areas teemed with plague. Filth filled the streets and the sewers were but open canals. In 1807 the city began extensive municipal improvements and in 1811 it purchased about six acres of the Kip’s Bay Farm along the East River. Belle Vue Place, along one border, already contained a building — the first to bear the name of Belle Vue Hospital. It had been used off and on while the city tried to cope with the persistent threat of yellow fever. A considerable proportion of the hospital staff was occupied in burying the dead. Belle Vue had established its own cemetery nearby in 1757 — this may well be another “first” among American hospitals but for some reason the public relations staff seems to ignore it.
New York’s ambitious plans ran into a major snag in 1812, when the US decided it was time for another war with Britain. It was not until 1814 that any progress was reported in alms construction and finally, in 1816, the buildings were open “to receive their guests.” The buildings were built to last (perhaps they expected another British invasion), as they were constructed of gneiss rock from the immediate area. It was around this time that Belle Vue was first contracted to “Bellevue.”
New Rules for a New Century
The medical department was reorganized in 1800, with the appointment of a salaried officer to act as physician, surgeon, accoucheur and apothecary. Dr. William McIntosh served in this capacity for five years, at which time the medical staff was doubled and an apothecary added. A second physician was rarely employed, however, until by 1817 it was realized that one doctor could not care for over 200 hospitalized patients. Night calls and delivering babies became ever more frequent, and a house physician also had to prepare and administer all of the drugs prescribed by the visiting doctor. Staffing was now set at two visiting doctors and two interns.
Disease Strikes Back
Throughout the early part of the 19th century the hospital continued to expand in physical size and staffing in an attempt to cope with an ever-increasing case load which continued to include sporadic epidemics of yellow fever. Of the infectious diseases, typhus fever epidemics were by far the worst challenge, with a death rate of about one in 10 to 12.
In 1825 both resident physicians became ill with typhus; Dr. Belden died. He was but the first of many doctors to give their lives while on duty at Bellevue; by 1884, 27 house staff doctors had died from diseases contracted during their hospital service.
Thanks to political mishandling and exploitation, Bellevue Hospital endured a long period early in the 19th century that caused even the most loyal employees to desert. Controlled by ignorant political appointees, the mismanaged hospital became a shambles. The mortality rate averaged 20 percent, one year reaching 33 percent. Conditions were pitiful; supplies had been plundered; the farm was neglected and little food was available. In 1837 eight nurses and servants “escaped” from Bellevue, leaving the sick to fend for themselves. What drove them to this action? “The whole concern was filled with typhus from top to bottom. The patients were lying in their filthy blankets, destitute of sheets and pillow-cases, and in some chronic cases they had not had a change for three months....” There was not even any Indian meal for poultices — no rags to dress the wounds.
Finally the commissioners took measures to improve the situation. Part of the solution was to free the hospital of the burdens of also being a penal institution. Male prisoners were sent to a new penitentiary of Blackwell’s Island. Smallpox patients followed. Female prisoners were sent to the Tombs, and the lunatics were removed to a new asylum, also on Blackwell’s Island. It took 10 more years before the alms house was also removed. By mid-century Bellevue had a new board comprised of the most distinguished physicians and surgeons in New York, and the institution began to assume its rightful role in community medical care.
It was at this time that the hospital took on a new role — that of medical education. The resident physicians had been required to attend meetings before, but most of these were of a political nature, and the teaching had mostly been confined to the wards. A new Medical Board now introduced a course of clinical lectures on both medical and surgical subjects.
Improved medical care was reflected by a steadily decreasing mortality rate. In 1847 it was 17 percent and it dropped each year until by 1853 it was just over nine percent. Unfortunately, in that year an unusually virulent typhus claimed the lives of two more staff physicians. Typhus and cholera caused many of the deaths in subsequent years. Puerperal fever was also on the increase.
Heroes without Medals
Nearly all of Bellevue’s younger staff physicians volunteered for service during the Civil War, and those who remained behind fought their own battle against yet another typhus epidemic handicapped by an acute shortage of professional help. Of the 21 members of the staff, 14 became ill with the fever and six died. For them there were no medals, for their families, no pensions. And the survivors were rewarded by a steadily increasing patient load. Somehow the hospital services continued. Meanwhile events were taking place in the Union Army under General Grant, which would not only affect Bellevue Hospital, but impact hospital services around the world. These commenced when Dr. Edward B. Dalton, a Bellevue staff surgeon, was appointed “Inspector for the Army of the Potomac.”
Dalton had joined the armed services as a regimental surgeon early in 1861. He exhibited considerable talent in medical administration and rose rapidly in rank. Coinciding with the campaign of 1864, Dr. Dalton was placed in complete charge of the transportation and care of the wounded. During the month of May he organized corps hospitals which accepted and cared for thousands of wounded men. By June he had created the Depot Field Hospital of the Army of the Potomac, where he was Chief Medical Officer, with facilities for care for 10,000 wounded and disabled soldiers. By the end of October, 68,540 sick and wounded had spent at least 48 hours in this hospital.
Caring for all these individuals was a major accomplishment, but the logistics of getting them to the hospital were even more impressive. It was necessary to organize a huge horse-drawn ambulance service and coordinate it with mobile hospital stations that were in close communication with the front. The system worked well, and when the war ended, Dalton was thanked by the War Department for his meritorious services.
Dr. Dalton next accepted a job as Sanitary Superintendent for a region that included New York, Brooklyn, Richmond and Westchester Counties, plus several small towns. In 1869, while considering an outpost of Bellevue to act as a reception hospital, he submitted plans for the hospital to develop an ambulance corps based upon the highly efficient system that he had run in the Army. These plans were so beautifully detailed that the commissioners immediately adopted them.
The commissioners authorized two ambulances for Bellevue Hospital of the type recommended by Dr. Dalton. Furthermore, “Each ambulance shall have a box beneath the driver’s seat, containing a quart flask of brandy, two tourniquets, a half-dozen bandages, a half-dozen small sponges, some splint material, pieces of old blankets for padding, strips of various lengths with buckles, and a two-ounce vial of persulphate of iron.” The Abbott-Downing Company was chosen to construct the vehicles, and in June 1869, the world’s first hospital ambulance service trotted into action at New York’s Bellevue Hospital.
The venture into emergency medical services proved such a success that five more ambulances and horses were added the following year. By 1891 Bellevue had 4,392 ambulance calls, but by that time a service at Chambers Street had 3,021 calls and ambulance service was also available at New-York, Roosevelt, St. Vincent’s and Presbyterian Hospitals. Ambulance drivers had to be familiar with the geography and traffic flow of the city. An ambulance was given the right of way over all other vehicles except fire department apparatus and US mail wagons.
Ambulances were of high quality construction and weighed only 600 to 800 pounds. A movable floor could be drawn out to receive the patient, designed for easy cleaning and disinfection. A drop or “snap” harness was used and the corps took pride in rapid response to emergencies. It was claimed that an ambulance could travel a mile in five to eight minutes in the business district. The ambulance carried a stretcher, splints, cotton and oakum. Equipment also included handcuffs and a straitjacket. The surgeon’s bag included medications, antiseptics and gauze.
It is a testimonial to the soundness of Dr. Dalton’s concept and the brilliance of his organizational ability that the ambulance service continued into the era of motorization. In medical emergencies, where prompt intervention is essential, the ambulance has proved its value on countless occasions.
The New Profession
Bellevue Hospital could increase its capacity, modernize its facilities, upgrade its medical staff, and introduce the revolutionary concepts of antisepsis and sanitation, but there was a serious deficiency that limited its capacity to offer good medical care. Nothing could overcome the low level of nursing care. From its inception, Bellevue Hospital had depended upon people from the penitentiary to fill the jobs of nurses, attendants or helpers. Most of them worked without pay for the sake of board and lodging. It is unfair to paint them all with the same brush and accuse them of indifference or dishonesty, for some no doubt felt compassion for those unfortunate folk who were both ill and indigent, but the majority were uneducated and incompetent.
Finding women who had the emotional stability, patience and endurance to be nurses was difficult enough, but only by education could these attributes be focused properly to provide quality nursing care. Mrs. Louisa Lee Schuyler, a brilliant woman who had founded the State Charities Aid Association in 1872 for improving public charitable institutions, came to the aid of Bellevue Hospital by establishing a Visiting Committee of 60 women with ability and social status.
Among these women, Mrs. Joseph Hobson recorded graphic descriptions of her first encounters with the hospital. She and three other committee members were conducted through the wards by one of the Commissioners of Charities. Never even having been in a hospital before, she emerged in shock. The dim lighting, the smells and the gloomy atmosphere were almost more than she could bear, but thankfully she met Dr. Gill Wylie, a young intern who offered to let her follow him around and observe the conditions in a casual manner.
Together they glanced at the long tables where the Friday dinner of salt fish was being dumped from a bag. There were no dishes, no knives or forks. He quietly explained that the scraps that fell to the floor would be efficiently removed at night by the rats. They peered into a kitchen, where the soup and coffee were prepared in the same greasy kettle, and the bathrooms, where the “10 day women” (drunks and prostitutes) slept on filthy rags. Finally they visited the laundry, where a feeble old man was stirring a kettle with a stick. His supply of soap had given out six weeks before.